This morning…
Working with substance abusing
clients
Not just a specialist field
Assoc Prof Lynne Magor-Blatch
University of Canberra
National Convener, APS Substance Use Interest Group
Chair, IDIS Project
• Working with AOD clients – psychologists in the
field
• What’s the problem?
• Drug use in Australia
• Overseas comparison
• Harm Minimisation
• Why people use
• Brief history of drug use in Australia and
worldwide
• Case histories
• IDIS Project
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Working with Alcohol and other Drug
(AOD) clients
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Psychologists in the AOD field
• The Alcohol and other Drug (AOD) field is a varied
landscape – and encompasses a continuum from early
intervention and education, through minimal intervention
to targeted treatment services
• Psychologists work within the field in various capacities –
and at all levels from research to primary, secondary and
tertiary intervention.
• Managing clinical services, providing group and
individual counselling, administration of a variety of
psychometric testing, case management and clinical
supervision and training of other staff.
• Treating the client "as an individual, being welcoming,
empathic, understanding, and demonstrating respect
and active, persistent caring, are among the trademarks
of services that hang on to clients".
• Psychologists offer their training in research and
evaluation, and understanding of human behaviour and
emotional processes to encourage evidence-based,
impartial debate on potential strategies and solutions.
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Psychologists in the AOD field
Psychologists in the AOD field
• Role to play in assessment and treatment of
problematic substance abuse behaviours, as well
as applying skills to better understanding and
prevention of substance misuse.
• Demonstrate efficacy and effectiveness of
interventions.
• Non-judgemental and compassionate approach
recommended and respectful.
• People are active shapers of their own change
processes and empowering clients is
fundamental to sustainable and ongoing change.
• Positive therapeutic relationship is major
component of effective psychological treatment.
• Co-morbidity highly likely when there is
substance misuse.
• Psychologists bring to the AOD field a unique
contribution in terms of assessment and
treatment planning. This may be further
enhanced through the use of psychometric
testing.
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Psychologists in the AOD field
What’s the problem?
• Promotion of social and emotional wellbeing.
• Broader view of prevention, drug use is one of a
range of problem behaviours, and should not be
seen in isolation.
• Work collaboratively with others concerned with
problem behaviours, including crime, suicide and
educational problems, to address the shared
pathways to these outcomes.
• Drug use not simply an individual behaviour, but
part of a wider issue, shaped by macroenvironmental factors.
• Psychologists provide an important resource in
terms of program design and evaluation.
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• Over 6.6 million Australians have used an illicit drug in
their lifetime (AIHW, 2008).
• Almost two in every five Australians (38.1%), aged 14
years or older, have used an illicit drug at some time in
their lives with more than one in seven (13.4%) have
used illicit drugs in the previous 12 months (AIHW, 2008).
• Most common types of drugs used among Australians
are marijuana/cannabis, Ecstasy, meth/amphetamines,
and pharmaceuticals.
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Current level of drug use in Australia
Current level of drug use in Australia
NDS Household Survey 2010
• Vast majority of Australians use caffeine, through tea, coffee,
cola drinks and chocolate.
• 80.5% of the Australian population consumed alcohol (down
from 82.9% in 2007) and 18.1% (down from 19.4% in 2007)
used tobacco over a12 month period in 2010 (AIHW, 2011).
• 14.7% (an increase from 13.4%) reported using an illicit drug
in past 12 months.
• Recent Cannabis use increased from 9.1% to 10.3% within
the last 12 months, and 35.4% (compared to previous
33.5%) had ever used Cannabis during their lifetime (AIHW,
2011). NB. Tobacco use as high as 74% among drug users.
• As comparison – Heroin use remained stable at 0.2% in past
12 months (AIHW, 2011).
• Use of licit drugs such as tobacco and non-risky
alcohol consumption is on the decline.
• Higher support than in previous years for the
implementation of tobacco and harm-reduction policies,
which were nominated as the drugs of most serious
concern in the community.
• Despite these positive gains, however, there has also
been an overall increase in the use of illicit drugs,
particularly cannabis, pharmaceuticals for non-medical
purposes, cocaine and hallucinogens.
• The full report can be found at
http://www.aihw.gov.au/publicationdetail/?id=32212254712&tab=2
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A comparison
Country
Marijuana/cannabis
Ecstasy
Meth/amphetamines
Cocaine
Opiates
Australia
10.6
4.2
2.7
1.9
0.4
New Zealand
13.3
2.6
2.3
0.8
0.4
Republic of Ireland
6.3
1.2
0.4
1.7
0.5
USA
12.3
1.1
1.6
2.8
0.6
Canada
17.0
1.3
1.0
2.3
0.2-0.4
England and Wales
7.4
1.5
1.0
2.3
0.9-1.0
Scotland
11.0
3.2
2.2
3.8
1.5-1.7
Northern Ireland
7.2
1.8
1.0
1.9
0.1
Source: Adapted from United Nations Office on Drugs and Crime (UNODC) 2009. Note: (a) The
methods, including age groups, vary for deriving prevalence. The specific data years also vary from 2000
to 2008 due to the timing of data collection in each country.
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Working in the context of the
AOD sector
• AOD sector is complex and some practices
may seem contradictory
– eg. Legal drugs such as alcohol and tobacco
cause greater harm in our society than illicit drugs
and Government policy attempts to minimise harm
rather than to eliminate drug use
– Recognition that zero tolerance does not prevent
drug use
Illicit drug use in Australia seems moderate to high
compared to similar countries.
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Harm Minimisation
Questions
• How do changing social, political and economic
contexts impact on work in the AOD sector?
• Why do you need to consider the
interrelationship of issues that affect clients?
• Harm minimisation provides a range of options
aiming to improve health, social, and economic
outcomes for both individuals and communities,
which encompass:
1. Supply reduction (strategies designed to
disrupt the production and supply of illicit drugs);
2. Demand reduction (strategies designed to
prevent the uptake of harmful drug use, including
abstinence-oriented strategies to reduce drug
use); and
3. Harm reduction (strategies designed to reduce
drug-related harm for particular individuals and
communities).
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Brief history of substance use and its
regulation
Why do people use drugs?
• Social activity
• Relaxation
• Stress relief or
control
• Pain relief
• Peer pressure
• Rebellion
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• Curiosity
• Part of a religious
ceremony
• Response to
loneliness
• Emotional pain
Main reason people start – plain curiosity.
The main reason they stop – no longer applicable or
fits within life.
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Brief history of substance use and its
regulation
• The consumption of alcohol dates back at least 8,000
years
• Tobacco has been used for thousands of years
• Opium use was evident in Mesopotamia at least 7,000
years ago
• Cannabis has been known by many names in many
languages over the course of human history
• Hallucinogenic mushrooms are referred to in ancient
Hindu texts and there is archaeological evidence dating
back to at least 7,500 BC of the use of an hallucinogen
derived from cactus
• There is a wealth of evidence showing that drunkenness,
and associated public disorder, has been widespread
throughout history
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Brief history of substance use and its
regulation
• Coffee houses became the meeting places for political
radicals and intellectuals during the 17th century - coffee
viewed as an evil substance.
• Charles II wanted coffee banned and women petitioned
that coffee “made men unfruitful, ‘disorders domesticity’,
and interfered with business”.
• In Arab countries in the 16th century, prohibitions were
placed on coffee, and some sellers of coffee beans were
executed.
• A contrast is the history of tobacco use, which was once
widely accepted and encouraged, but is now increasingly
regulated and socially unacceptable.
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• British controlled most of the opium poppy cultivation and sale in
India in the 18th and 19th centuries.
• Germans involved in the production of cocaine in the 19th century.
• Political conflict over control of territory and supply routes
occurring since at least the 16th century.
• Through the Opium Wars with China in the late 17th century,
Britain established control over the opium producing areas of
India.
• Always hidden political agendas: eg. in the United States, ending
the world trade in opium was important to appease the Chinese
government to ensure their cooperation in supporting the US as
the world economic power.
• Outcome is that particular societal groups, through their use of
prohibited substances, become classed as deviant and may even
be demonised within the wider society.
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Australian Drug History
Australian Drug History
• Laws regarding legality or illegality of certain drugs politically
driven - little to do with the level of use or possible harms that the
drug, itself, might cause.
• Restriction of opium began in Queensland in 1897, with the
Aboriginal Protection and Sale of Opium Act which made it
unlawful for doctors, chemists and wholesale druggists to possess
or supply opium, but only if it was intended for sale to Aboriginal
peoples.
• Restrictions extended to Asian migrants in response to concerns
regarding the ‘yellow peril’.
• White Australians continued to purchase opiates over-the-counter
until the World War II, and doctors continued to prescribe heroin
for labour pain and the terminally ill in Australia until 1953.
• In response to pressure from the United States, the importation of
heroin banned in 1953, and the States and Territories followed
suit to prohibit over-the-counter sales of heroin preparations.
• Britain has never completely outlawed heroin
preparations, although their use has been heavily
restricted since 1908.
• Britain continues to use heroin in clinical settings, eg.
British Medical Journal in 2001 reported results of a
randomised trial of nasal diamorphine (heroin) for
analgesia for children and teenagers with clinical
fractures, concluding that nasal diamorphine spray should
be the preferred pain relief over intramuscular morphine.
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John’s story – age 23
Jane’s story – age 55
• Jane has been in the Public Service for 30 years – since leaving
university as a graduate and gaining entrance to the Graduate
Program
• She has had a number of different appointments and in different
government departments, but has been in Foreign Affairs for the past
25 years
• Jane has had a number of overseas appointments, and on one of her
early appointments to the UK met and married William, with whom she
has 2 children – Kim aged 20 years and Brad aged 18 years. William
and Jane divorced 10 years ago
• Jane first started drinking at university and admits that it was ‘out of
control’ for a bit. For a while it was OK, but increased again with the
many cocktail parties and events she was required to attend with
Foreign Affairs. After her divorce her drinking increased once again
• Jane now drinks 1-2 bottles of wine daily. She keeps a bottle in her
car and pops down to the car park during work
• It has now come to the attention of her supervisor
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Ben’s story – age 17
• Ben is 17 and still at school. He wants to do something with his
life. He hopes to finish school and get a job. If he can’t find one
near home he might join the defence forces. His career advisor at
school said that was a good way to make a start. His dad has a
job and mum works part-time. They want him to do well.
• Ben only smokes a bit of cannabis when he’s out with friends
who are smoking. He never buys the stuff for himself, but if
they’re smoking he’ll occasionally join in. He smokes the
occasional cigarette for the same reason. He really just doesn’t
want to be seen to be different – he’s Aboriginal, and it’s hard
enough that he is one of the few still at school!
• A couple of times at parties he has tried Ekkies (Ecstasy). They
made him feel good but they are expensive and he can’t afford
them regularly. So generally at a party he sticks to grog.
Sometimes, he drinks too much and ends up really drunk like
most of his friends, but often he just has a few.
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• I started using drugs to fit in. I had always hung around with older
people and they all seemed to use, also my older brother did as well. I
started dabbling with alcohol at the age of 9 and as I became older I
experimented with other drugs. I really loved what they did for me,
they gave me security, helped me fit in, gave me courage and took
care of any emotional pain I found hard to deal with.
• By the age of 15 I was taking drugs on a regular basis. This continued
until I was 16, by then I had a reasonable drug habit. On my 16th
birthday I was informed my father had bowel cancer. This was very
hard to accept. We were told he had six months to live. My whole
family was dealing with it by talking to one another.
• With this news I went a lot harder with the drugs, as it was the only
way I seemed to deal with the news. My father promised me he would
live to see my 21st birthday. He did last longer than 6 months and over
the years he progressively became worse and so did I. My father did
live to see my 21st Birthday. He died 7 days later. That was 2 years
ago. Since then things have got worse.
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IDIS Project
• Australian Government $20.1 million Illicit Drugs in Sport
(IDIS) - National Education and Prevention Action Plan to
help tackle illicit drug use in sport and in the broader
community
• Under the Government’s $20.1 million IDIS Action Plan:
– Professional and non-professional sports will have access to
Government funded education programs targeted at elite
athletes, coaches and sport administrators
– Sport role models will help deliver community education and
prevention initiatives about the harms associated with illicit drug
use at a community level
– National Sporting Organisations can apply to the Australian
Government to help conduct out of competition testing for illicit
drugs and result management
– An evidence base will be developed through ongoing research
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IDIS Project
FREMANTLE
Dockers utility
Michael
Johnson has
been fined $500
after pleading
guilty to cocaine
possession.
• The Rehabilitation and Counselling component of the
plan aims to ensure the highest level of support and
rehabilitation is available to athletes identified to have
engaged in illicit drug use
Cats player Mathew Stokes outside Geelong police
station after drug charges were laid
• Under the Plan sports will be provided with referral advice
to appropriate expertise to assist in counselling and
rehabilitation measures for any athletes in this situation.
Given the links between substance abuse and mental
health, this will include, where appropriate, mental health
agencies
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Andre Agassi risked a significant gaol term if he had been
caught using crystal methamphetamine 12 years ago. In
1997 he had snorted crystal meth and had been caught by
the sport's drug testers only for him to plead ignorance,
blame an accomplice and get off scot-free.
Former Australian Rugby League
captain and Newcastle Knights star
Andrew Johns has been arrested in
London for possessing an ecstasy
tablet.
In a stunning confession to The Daily
Telegraph, Johns candidly discussed
his longlong-term drug and alcohol
abuse and his battle with
depression. He admitted taking
ecstasy and "other drugs"
throughout his stellar career - but
somehow managed to avoid
detection by NRL drug testers.
AFL players recorded 14 failed drug tests in 2009, with two
players failing a test for a second time. 13 of the 14 positive tests
were for stimulant drugs, only one player testing positive for
canniboids, with cocaine said to be the illicit "drug of choice" of
players based on results of the past two years. Ice and Ecstasy
use was also discovered.
Previously found
with one
Ecstasy tablet.
Ben Cousins - Tried pot at about 13 and didn't like it.
Use of methamphetamine, cocaine.
cocaine Bender stretched
to LA, where he ingested cocaine every 20 minutes or
so for five days. After a while, he ate it instead of
snorting it. In Sydney, he was holed up for days
watching a man called “The Chef “cook cocaine
powder into crack cocaine.
He kept passing out on another drug, GHB.
GHB A mate
turned Cousins on his side when he was choking on
vomit.
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FATHER AND SON
Drug Use Has Many Faces
The Personal Experiences of Bryan Cousins,
Karl O'Callaghan & Tony Trimingham
Chaired by
James Pitts
CEO, Odyssey
House
Drugs – licit and illicit, prescribed and non-prescribed, can all have
an impact on the lives of those who use them and the people who
love those who use. Three men speak about their experience as
fathers with sons impacted by drug use.
The human side – and the families involved is too often forgotten.
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Emergence of drug use as a
problem in sport
• Practice of enhancing performance through foreign
substances or other artificial means is as old as competitive
sport itself –
– Ancient Greek athletes were known to have eaten special diets and
taken stimulating remedies to fortify themselves.
– In the 19th century, amphetamines and drugs such as caffeine,
cocaine, strychnine and alcohol were most commonly used by
cyclists and other endurance athletes.
– During the 1904 Olympic Games, Thomas
Hicks ran to victory with the help of raw egg,
injections of strychnine and doses of brandy
administered to him during the race.
– By the 1920s, it had started to become
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apparent that restrictions regarding drug use in sports necessary.
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Emergence of drug use as a
problem in sport
• 1960s: steroids were becoming widespread in the United
States and Eastern Europe.
• 1980s: number of high profile drug scandals (e.g., Ben
Johnson, 1988)
• Sporting bodies introduce anti-doping policies and
regulations surrounding their use
• 1998: Tour de France drug crisis in cycling led to push to
establish an agency whose sole responsibility it would
be to manage and enforce anti-doping policy.
• 1999: World Anti Doping Agency (WADA) was founded
in 1999 and has been at the forefront since that time
• 2006: Australian Sports Anti Doping
Authority (ASADA) established
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Emergence of drug use as a
problem in sport
Who cares about the risk?
• More recently, sporting organisations in Australia have
recognised the importance of implementing illicit drugs
policies, alongside detection and prevention practices
• To date, little research investigating illicit drug-use
patterns among Australian sporting populations, most
notably at the elite level.
• Majority on prevalence rates among athletes using
secondary and tertiary student populations (Backhouse,
McKenna, Robinson & Atkin 2007).
• Much of the research explored substances considered to
be performance-enhancing (e.g. anabolic-steroids), licit
substances (e.g. alcohol) and ergogenic nutritional/sport
supplements (e.g. creatine).
• 1997 Sports Illustrated interviewed a cohort of
elite Olympic athletes and posed the question:
– "If you were given a performance enhancing
substance and you would not be caught and win,
would you take it?"
• 98% of the athletes responded "Yes".
• More alarmingly, over 50% of participants
responded “Yes” to the question:
– "If you were given a performance enhancing
substance and you would not be caught, win all
competitions for 5 years, then die, would you take it?"
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Who cares about the risk?
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The extent of the problem
• In Australia, alcohol is a significant problem amongst the
general population.
• Part of Australian sporting life, especially
in sporting cultures where it is common
to go for a beer after the game, or an
end-of-season team trip where binge
drinking is part of the culture.
• Research has found that sport has a positive influence on
adolescents’ use of alcohol and other social drugs.
• However other studies have shown that involvement in
sport as an adult may actually encourage greater intake
of alcohol.
• The full extent of the illicit drug problem in sport in not
known.
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The extent of the problem
• Recent Australian study (Dunn et al., 2009)
investigated substance abuse among elite
Australian athletes
– 974 athletes were surveyed from a range of sporting
organisations, such as rugby league, athletics, diving, and
netball
• Findings:
– 1/5 reported “lifetime use” of cannabis
– 1 in 10 had tried Ecstasy at some point in their life
– Lifetime use of an illicit drug ranged from 0.8% (GHB) to
21.0% (cannabis)
– past-year use of illicit drugs was low at 0.2% to 3.7%.
– 16% indicated Ecstasy, alcohol, cocaine, steroid and
cannabis as DOC
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The extent of the problem
• Results positive, considering 32.5% (n=317) of sample indicated
that they had been offered, or had the opportunity to use, at
least one illicit drug in the past year (Dunn et al., 2009)
• Overall, athletes’ self-reported use of illicit substances was
lower than that of the general population
• Cross-sample of elite Australian athletes found that vast
majority perceived that at least some athletes in their sport had
ever used or currently use illicit drugs (Jalleh & Donavan, 2008)
• 29% English football players believed that illicit drugs were not
used by players
• 45% indicated personally knew players who used recreational
drugs
• Use of illicit drugs reported as more widespread than
performance enhancing drugs (Waddington et al., 2005)
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• Little research investigating the determinants of illicit drug
use in sport, particularly at the elite levels
• Major research has focused on banned performanceenhancing drugs, with little emphasis on illicit drug use for
recreational purposes
• To date, the predominant view on doping holds to an
implicit assumption that licit and illicit drug use by athletes
follows the same principals as the general population
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Theories and models
• In seeking to explain drug-use behaviour among athletes
(as a sub-population of all drug users), a number of
theories (or models) have been devised
• Some stem from evidence on licit and illicit substance
use outside of sport, and provide some conceptual
background for athlete substance abuse (e.g. the social
cognitive model and the lifecycle model)
• Some have arisen from the sociological and
pharmacological domains and others have arisen from
data specifically relevant to the sporting context (e.g. the
grounded model)
Theory or Model
Brief Description
Reference
Technological
explanations: the
pharmacological
revolution
Increase largely explained by the
improvements in chemical technology
Mottram (1988, 2005);
Verroken, (2005);
Donohoe & Johnson
(1986); Coakley and
Hughes (1994, 2007a)
The hypothetical lifecycle model
Characterised by (a) combination of trait,
systemic and situational factors (b)
developmental approach & (c) the assumed
outcome expectancy leading to functional use
of performance enhancing substances by
athletes
Petrockzi & Aidman’s
(2008)
The deviant
overconformity
framework
Drug seen as a deviant overconformity. Use
by athletes expresses acceptance &
overconformity to key values, (e.g., value of
winning)
Coakley and Hughes
(2007b)
Marxist theory
Drug use indicative of alienation of individuals
(i.e. athletes) in modern capitalist societies
Luschen (1993, 2000)
Mertonian approach
to deviance
A typology of behaviour based on cultural
goals and institutional norms
Merton (1957)
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Theory or Model
Brief Description
Reference
Theory of differential
association
Network of relationships between users
and suppliers. Use of illicit drugs ‘is
performed as part of a deviant
subculture, or ‘secret societies’. Subculture of drug-using athletes, and
suppliers of drugs; coaches, physicians
and other members of the ‘doping
network’
Sutherland and
Cressey (1974)
Socio-psychological game
models
‘Doping game’ models regard drug use
in sport as ‘a decision dilemma’, and
moral dilemma. Athletes may have
different values but are thought to think
and act rationally to maximise best
outcomes for themselves
Breivik’s (1987,
1992)
Sporting careers, biographical
risks and doping
Suggests life involves risk, athletes are
also subject to special circumstances
that don’t appear in other social sectors,
a to comparable degree in elite sport of
an earlier period. Identifies typical risk
factors of athletic careers and suggests
that drug use can be seen as a coping
strategy that grows out of these specific
risks.
Bette (2004)
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Theories and models
• Theories provide some value in understanding
drug use in elite sport, little literature is available
on applying behaviour change theories to better
understand the determinants of drug use
behaviour among athletes:
–
–
–
–
The Health Belief Model
The Theory of Reasoned Action
Theory of Planned Behaviour
The Transtheoretical Model
(Stages of Change)
– Social Cognitive Theory
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Determinants of drug use
behaviour amongst athletes
Objectives of the education and
training program component
• Behavioural, physical, psychosocial, and
contextual/environmental factors
• These include:
• Develop an online education and training package on treatment
of illicit drugs in sport issues to support the implementation of
the program
• Promote and deliver the training programs to APS members
with existing substance abuse qualifications and other providers
– Coping with pain, weight control, recovery, physical
image, assist with performance demands
– Personality, stress, anxiety, coping mechanisms,
perceived benefits, self-efficacy & self-confidence,
social support, personal problems, mental health,
influence of friends & family
– Culture, career transition, financial incentives
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Reference Group Members from APS –
• Lynne Magor-Blatch (Chair), ATCA and University of Canberra
• Stefan Gruenert, CEO Odyssey House, Victoria
• Debra Rickwood, University of Canberra and Headspace
• Melissa Norberg, NDARC
• Geoffrey Paull, Counselling Psychologist
• Tracey Veivers, Sports Psychologist
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Training Modules
• Module 1 (Illicit Drugs in Sport) – core education and
training module: Targeted to psychologists who might be
involved in working with sports people who have been
identified or self identified as having a problem with illicit
drugs in relation to their sporting activities
• Module 2 (Illicit Drugs in Sport) - specialist education and
training: Targeted to psychologists with experience
working in the alcohol and other drug area. This training
focuses on specific treatment issues related to sports
people and illicit drug use
• As a result of the training, psychologists identified in all
States and Territories with specialist counselling skills
and trainers to provide training to athletes, coaches and
sporting clubs.
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