Case Description
Patient M was admitted to a psychiatric hospital with severe symptoms of psychosis. M is 26 years old and single. M exhibited slowly increasing (and possibly leading to death or severe functional impairment) deterioration of health as a result of mental inability to take care of oneself is also quite dangerous. M was diagnosed with methamphetamine abuse which started approximately 4.5 years ago. Despite the fact that the physical examination data are not specific to drug abuse, a thorough medical examination is additional confirming to clinical diagnosis and allows one to create guidelines in determining the severity of the condition. Thus, patient M showed traces of intravenous injections along the superficial veins.
In addition, examination of the neurological state (pupillary reaction, nystagmus, tremor) and somatic state (including percussion of the liver, kidneys, heart auscultation, measurement of blood pressure, heart rate, NPV) also showed the presence of prolonged drug addiction and general intoxication of the body. Enzyme immunoassay at primary urine screening for psychoactive substances and mass spectrometry confirmed the diagnosis. M also reported disturbances in mood, sleep and exhibited decreased mental performance. Despite the systematic use of the drug and an increase in tolerance, as well as withdrawal symptoms, M denies his dependence on a psychoactive substance.
Identification of the Aspect Targeted For Rehabilitation
Patients with a combination of mental and drug addiction pathology adapt much worse in society and are relatively more likely to have low compliance (Maruta et al., 2016). Substance addicts have a fairly well-developed sense of reality that allows them to navigate the world around them, but in cases of severe frustration, they do not use adaptive ways to resolve conflicts and overcome difficulties (Russo et al., 2021). The predominance of primitive mechanisms of psychological defense (denial, splitting, regression), the effect of which is traced in their reactions to frustration, does not allow them to maintain mental balance and provokes the use of psychoactive substances (Rivera et al., 2017). Patients cannot withstand emotional stress that exceeds the usual level. Even relatively minor difficulties cause them to increase symptoms and behavior regression (Salas-Wright et al., 2017).
Personality traits and fundamental beliefs have a significant impact on people’s behavior. Several studies have shown that personality traits and basic beliefs are highly correlated with addictive behavior (Zilberman et al., 2017). From 30 to 60% of addicts meet the diagnostic criteria for antisocial personality disorder, while in the normal population, this figure does not exceed 2-3% (NIDA, 2021). Depressive and psychopathic disorders have the highest frequency of personality disorders (Beaufort et al., 2017).
If, at the inpatient stage, the most urgent tasks are solved (development of attitudes for treatment, overcoming anosognosia, the formation of attitudes for sobriety), then at the outpatient stage, work is built with personal problems (Alessi et al., 2020). Among the latter – the development of stress resistance, the ability to resist their own compulsive states, learning to maintain relationships with other people, adaptive protective strategies, and mental development issues (Alessi et al., 2020). An optimal understanding of the underlying beliefs and mechanisms of psychological defenses of persons with addictive behavior allows for more comprehensive planning of treatment for these patients in accordance with their dominant beliefs and reasons. In addition, it provides opportunities for the development of more effective prevention programs (Chan et al., 2019). At this stage, the most important challenge is an intervention to combat addiction denial. Without accepting the fact of addiction, the patient cannot be adequately cured (Pickard, 2016). Therefore, taking the problem is a major essential step towards the rest of the interventions, both inpatient and outpatient.
Rehabilitation Process
Rehabilitation is based on understanding chemical dependence as a multifactorial disease affecting all aspects of the patient’s personality. At the same time, its various symptoms, including denial, are caused by neurocognitive dysfunctions (Dean et al., 2015). Also, drug addiction can be likened to any other chronic disease and, just like in other chronic diseases, achieve remission (Fleury et al., 2016). The duration of this remission determines the quality and content of basic rehabilitation. It is possible to ultimately save the patient from physical dependence within a few weeks, but the main problem of this disease lies in psychological support and its denial by the patient themselves.
According to the American Society of Addiction Medicine definition, addiction is “a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases” (ASAM, 2019, para. 6). The dysfunction leads to characteristic manifestations in the biological, psychological, social, and spiritual spheres of a person’s life, which is expressed in a pathological desire to receive a reward and/or relief through the use of various substances, as well as other behavior. As with other chronic illnesses, addiction often involves cycles of relapse and remission (Mauri et al., 2017). Without treatment or participation in recovery activities, addiction becomes a progressive disease and can lead to disability or premature death.
Counselors are involved in working with an addicted person mainly in those moments when they become capable of a minimum degree of intellectual activity, emotional response, and the ability to manage their behavior. Until this point, the dependent person should be dealt with rather by doctors and motivational workers of detoxification departments as well as nurses. It is known that awareness of addiction determines the effectiveness of its therapy (Zafar & Farhan, 2020). Denial is the most common type of attitude towards drug addiction and is present in almost all people suffering from chemical dependence, and manifests itself mainly in the stubborn distortion of the facts of the disease and its consequences (Stein et al., 2018). Denial aims to prevent a person from coming to a change in their behavior, including undergoing treatment. The main job of a nurse is to support the patient on their way to well-being, so that the treatment is more comfortable for them.
It is believed that denial changes within one addictive cycle, while it is maximum in remission of the disease. Its decrease during psychotherapy proceeds from the formation of cognitive recognition of the disease through its acceptance at the emotional level to motivational and behavioral changes (Potik, 2020). The role of a nurse in the treatment of an addicted person, on the one hand, is limited by the conditions of therapy and the client’s resources. On the other, it may seem limitless, given the huge list of client’s problems (social, psychological, interpersonal, biological, moral). Thus, it is critical for a successful treatment to establish so-called therapeutic relationship, a one based on trust. To enable that, a nurse has to provide correct and factual answers to any questions, address the patient respectfully, and avoid being judgmental (Vera, 2020). Such an approach will create a favorable atmosphere for overcoming the psychological barrier.
Denial is a set of unconscious reactions that protect a person from the pain that can be caused by the realization of serious problems and the need to take responsibility for solving them (Gorski, 2016). For example, when stressed, the brain can become emotionally overwhelmed and activate automatic defense mechanisms called “denial patterns” (Smith, 2020). There are several theories conceptualizing denial and, hence, various interventions. Ann Stoddard Dare and Derigne (2010) outline moral defect, interactional, mental impairment, psychodynamic, phenomenological, and stages of change theories. Nowadays the stages of change seems to be more appropriate for the reason that it presupposes motivational enhancement therapy as an intervention (Ann Stoddard Dare & Derigne, 2010).
As for nursing interventions in particular, nurses are responsible for showing the patient the connection between substance abuse and problems, which will be the initial step to a decrease in denial. This can be done by describing the effects of the substance or substances the patient has been taking, including mood and personality changes (Vera, 2020). Realizing that the problems root at the addiction may encourage the patient to begin abstinence.
The ability of the addict to control themselves, their thoughts, and desires is precarious. Pathological attraction changes their psychological state; this is especially pronounced in the first weeks after quitting use (Jones et al., 2016). The rehabilitation centers, which are based on the Twelve Steps rehabilitation program, combine common traditions, the rules of operation of these centers, and the direction of the structure of work (Enos, 2020). Alcohol, drugs, physical abuse, and evasion of responsibility are prohibited here; defined a daily routine in order to develop discipline. For people who have just come to the recovery program, telephone calls and letters are forbidden. The program’s goal is to change the patient’s value system, to help gain confidence in one’s ability to reason rationally and think abstractly (Galanter, 2018). Also, work is underway to facilitate the patient’s adaptation outside the rehabilitation center; they are taught the ability to make new friends, prepare to communicate with old acquaintances, if possible, and how to resist their influence and refuse the proposed dose.
The Twelve Steps program is one of the most effective drug and alcohol rehabilitation programs (Coco et al., 2019). It was created in the 30s in the USA, and then many other countries adopted this program (Galanter, 2018). Its essence boils down to recognizing that a person alone cannot cope with addiction to psychoactive substances and needs professional help. This program not only contributes to the acquisition of sobriety from psychoactive substances but also helps to improve the patient’s quality of life outside the rehabilitation center (Coco et al., 2019). The program is based on the bio-psycho-socio-spiritual model of the disease, and each aspect of it is crucial.
The role of a nurse grows even more significant here since the solution of the problem at this stage goes beyond medicine. The patient needs to realize and take the own responsibility for recovery, and the task of a nurse lies in assisting, encouraging, and supporting them on a continuous basis. It is also relevant to involve family members or other nearest people “to assist the patient deal appropriately with the situation” (Vera, 2020). Such an approach helps to replace denial with meaningful action, hence enable recovering.
References
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