Mantenimiento de las habilidades de rehusarse al consumo en usuarios crónicos de alcohol y drogas: un estudio de casos

• Autores: Marlene Flores Mares, Lydia Barragán Torres
• Localización: Salud mental, ISSN 0185-3325, Vol. 33, Nº. 1, 2010, págs. 47-56
• Idioma: español
• Títulos paralelos:
  • Maintenance of training on refusal skills in cronic users of alcohol and drugs: a case study
• Enlaces
  • Texto completo (pdf)
• Resumen
  • español

    En México, el consumo de alcohol y drogas ha sido un problema social. Los estudios epidemiológicos indican que el consumo moderado alto de alcohol ha prevalecido en los últimos años, se ha igualado la cantidad de ingesta en ambos sexos y alcanzado el consumo crónico hasta entre un cinco a 10% de la población. En lo referente al consumo de drogas ilegales, éste se ha incrementado tanto en hombres como en mujeres. Es indispensable que esta población tenga acceso a diversos tratamientos y se evalúe su impacto en la reducción de éste problema.

    El Community Reinforcement Approach (CRA) ha demostrado ser uno de los mejores programas de intervención para lograr la abstinencia en usuarios con consumo crónico de drogas legales o ilegales en los Estados Unidos. En México, la adaptación del CRA requirió modificar algunos de sus componentes y añadirle el de autocontrol emocional. A partir de estos cambios se estructuró el Programa de Satisfactorios Cotidianos (PSC) que favoreció la reducción significativa en el patrón de consumo en los usuarios participantes y el incremento en la satisfacción con su funcionamiento cotidiano. Este es un Programa intensivo, que integra diversos componentes en función de la gravedad de la problemática por modificar. Sin embargo, requiere la evaluación sistematizada de cada uno ellos.

    En un estudio con una población mexicana de consumidores crónicos, la habilidad para rechazar la presión social al consumo y los pensamientos de apetencia o necesidad por consumir funcionaron como precipitadores predictores de la abstinencia. El componente de Rehusarse al Consumo es uno de los más importantes ya que provee al usuario de las estrategias necesarias para negarse ante situaciones de ofrecimiento e insistencia en las invitaciones y en momentos en los que sus pensamientos precipitadores le activan la conducta de consumo.

    Las habilidades para rehusarse al consumo evaluadas en estos usuarios fueron: negarse asertivamente, sugerir alternativas, cambiar el tema de la plática, ofrecer justificación, interrumpir la interacción, confrontar al otro y su lenguaje corporal, así como el cambio de pensamientos precipitadores mediante el uso de la reestructuración cognoscitiva.

    El objetivo de este estudio fue evaluar el nivel de dominio alcanzado en las habilidades de rehusarse al consumo por cuatro usuarios crónicos de drogas del Programa de Satisfactores Cotidianos (PSC). Cada usuario realizó un análisis de sus situaciones de riesgo para el consumo ante la presión social y efectuó un ensayo conductual en el que ponía en práctica las habilidades. Posteriormente identificó sus pensamientos precipitadores y llevó a cabo un ejercicio en el que el terapeuta repetía en voz alta los pensamientos precipitadores del usuario y éste los cambiaba por pensamientos positivos orientados a modificar la decisión de consumir. Estos ejercicios fueron grabados y evaluados por dos terapeutas del PSC. Los resultados indican un nivel de dominio alto de las habilidades de rehusar el consumo ante presión externa e interna; adicionalmente, los usuarios aplicaron las habilidades de rehusarse a consumir en escenarios naturales. Redujeron sus episodios de ingesta, lograron mantener la abstinencia, disminuyeron las situaciones de ofrecimiento en las que tuvieron consumo e incrementaron su seguridad para no consumir al exponerse a ofrecimientos.

  • English

    In Mexico, alcohol and drug consumption has been a social problem for many years. Epidemiological studies show that moderate–to–high alcohol consumption has persisted in recent years, whereas in the case of illegal drugs consumption has become more widespread in both men and women. In fact, there is a tendency for consumption rates to level out between men and women, especially regarding legal drugs. Although most users are moderate consumers, between 5–10% are chronic consumers. It is necessary for these people to have access to a range of treatments that incorporate a system of examination and systematization. Consequently, in Mexico it is necessary to create new programs with a methodological structure that makes it possible to assess whether they assist in curtailing this social problem.

    One program that has proven to be effective is the Daily Satisfaction Program (DSP), which is based on the Community Reinforcement Approach (CRA). CRA is notable as one of the most successful programs in helping chronic users of legal or illegal drugs in the United States to give up substance abuse. In Mexico, it was necessary to modify some of the elements of DSP in order to adapt it to our culture, but it has encouraged a significant reduction in consumption patterns among participating users. This is an intensive program that includes several components, due to the serious nature of the problem to be tackled. However, it is necessary to carry out a systematized assessment of each of these components that foster in the user not only a reduction in consumption but also an increase in the satisfaction found in day–to–day activities. In Mexican culture, there are strong social pressures that affect consumption. Consequently the refuse–to–consume component is one of the most important, as it provides the user with the necessary strategies to be able to decline in a situation with peer pressure and in those moments when impulsive thoughts occur that might trigger the consumption response in the subject.

    The refuse–to–consume skills that were assessed in users were: body language, assertive refusal, suggesting alternatives, changing the subject of conversation, offering an explanation, suspending interaction, confronting the offerer, and changing impulsive thoughts by using cognitivist restructuring.

    Some investigators have detected a correlation between high consumption levels and a low degree of self–efficacy in refusing consumption. According to this theory, low self–efficacy in refusing consumption is the most accurate indicator of consumption behavior and makes it possible to discriminate between different types of user. High self–efficacy in refusing consumption is associated with less frequent episodes of consumption. With regard to motivation, these authors suggest that better self–efficacy in refusing consumption when offered the substance or in response to impulsive thoughts has an influence on the decision to consume or not to consume. In order to achieve a higher degree of self–efficacy in refuse–to–consume skills, it is necessary to control certain body responses that denote the desire or wish to consume. Some of these responses are: avoidance of eye contact, trembling, stuttering, blushing, sweating, palpitations, etc.

    The physiological responses associated with consumption are still displayed after the user has been through a period of non–consumption. They may be triggered by words associated with consumption or by watching videos of people who are consuming. Responses of this kind may be explained from a classical conditioning viewpoint, whereby a given stimulus provokes a given type of response. To explain what elicits, maintains, and increases the consumption of alcoholic drinks, three models of conditioning have been posited: the conditioned withdrawal model, the compensatory response model, and the conditioned motivational model. These models are based on an analysis of alcohol consumption situations with the aim of identifying the related variables.

    The model that most clearly explains alcohol consumption as a conditioned response is conditioned withdrawal. According to this model, in the case of people who have a history of alcohol dependence the stimuli associated with alcohol consumption (visual, olfactory, and auditory) provoke physiological responses such as salivation, trembling hands, or sweating. Alcohol consumption reduces these responses, which the subject is averse to. Users learn that, when they are offered a drink or drugs (the stimulus), they should accept it (the response).

    The aim of refuse–to–consume skills is to teach them to change their response to the stimulus, in other words, to teach users the necessary skills so that they learn to say no. When people are in the process of changing their consumption patterns by learning refusal skills and they experience high–risk situations, it is very probable that on the first few occasions they will exhibit a behavior that shows they are feeling insecure or anxious, such as avoiding eye contact with the person offering them the substance, stuttering, mumbling, not speaking with a decisive tone of voice, sweating, or having shaky hands. These responses make the offerer doubt whether the individual wishes to give up consuming, so he or she is more likely to insist and encourage a relapse in the user. Consequently, it is necessary to teach users how to react to these offers by relaxing and behaving assertively. This can be achieved by applying refuse–to–consume skills. Relaxation produces emotional effects that are the exact opposite of anxiety and which may be used therapeutically in everyday situations. Thus, it is less likely that the person offering the substance will follow up a refusal by repeating the offer, and the user may then take control of the situation and feel more secure. Peer pressure constitutes a high–risk factor that causes many users to relapse. It consists of direct or indirect pressure from other individuals or social groups who exert an influence on the user. In the case of direct pressure, the contact is personal, the offer involves verbal interaction, and the offerer is insistent that the user should consume the substance. In the case of indirect peer pressure, the user responds by watching other people use the substance in question.

    Often peers do not understand that the user has made a decision to quit and are insistent that he or she should continue to consume; the user also frequently feels that justification should be provided when refusing an offer. In reality, such an explanation is not necessary in most cases. It is frequently the case that when the user is with family members or close friends, they may question the refusal. For this reason, it is important for the user to preempt this reaction by asking friends and family members for support as a first step in the recovery process. The user must also interpret events, impulses, and emotions rationally, bearing in mind the negative consequences of consuming and the benefits of being sober or drug–free. Consequently, the user needs to learn to say no to him– or herself whenever temptation arises in the form of thoughts or desires. The user must confront them and change them into positive thoughts that favor his or her wellbeing and are unrelated to consumption.

    The objective of this study was to assess the degree of aptitude attained in refuse–to–consume skills by four chronic drug users in the Daily Satisfaction Program (DSP). Each user performed an evaluation of the high–risk situations in which consumption might occur as a result of peer pressure, and carried out a behavioral test in which the skills learnt were put to use. Subsequently, the users identified their impulsive thoughts and carried out an exercise in which the therapist repeated out loud the impulsive thoughts and the user replaced them with positive thoughts oriented toward reversing the decision to consume. These exercises were recorded and evaluated by two DSP therapists. Results indicate a high level of skill in refusing consumption in the face of external and internal pressure. Users also put these skills into practice in real–life situations, thereby reducing their episodes of consumption or maintaining abstinence.