Addiction psychology

Addiction psychology mostly comprises the clinical psychology and abnormal psychology disciplines and fosters the application of information obtained from research in an effort to appropriately diagnose, evaluate, treat, and support clients dealing with addiction. Throughout the treatment process addiction psychologists encourage behaviors that build wellness and emotional resilience to their mental and emotional problems.

The basis of addiction is controversial. Professionals view it as a disease or a choice. One model is referred to as the Disease model of addiction. The second model is the Choice model of addiction. Researches argue that the addiction process is like the disease model with a target organ being the brain, some type of defect, and symptoms of the disease. The addiction is like the choice model with a disorder of genes, a reward, memory, stress, and choice.[21] Both models result in compulsive behavior.

Cognitive Behavioral Therapy, Dialectal Behavior Therapy and Behaviorism are widely used approaches for addressing Process Addictions and Substance Addictions. Less common approaches are Eclectic, Psychodynamic, Humanistic, and Expressive therapies.[1] Substance addictions are relate to drugs, alcohol, and smoking. Process addictions relate to non-substance related behaviors such as gambling, spending, sexual activity, gaming, internet, and food.

History

The word 'addiction' has successfully been traced to the 17th century. During this time period, addiction was defined as being compelled to act out any number of bad habits. Persons abusing narcotics were called opium and morphine 'eaters.' 'Drunkard' referred to abusers of alcohol. Medical textbooks categorized these 'bad habits' as dipsomania or alcoholism[1] However, it wasn't until the 19th century when the diagnosis was first printed in medical literature. In the 1880s, Sigmund Freud and William Halsted began experimenting with users of cocaine. Unaware of the drug's powerful addictive qualities, they inadvertently became guinea pigs in their own research and, as a result, their contributions to psychology and medicine changed the world.

While working in Vienna General Hospital (Vienna Krankenhaus), in Austria, cocaine took possession over Freud's life when he found cocaine to relieve his migrane. When the effect of cocaine decreased, the amount of cocaine Freud consumed increased. With information about the pain suppressing properties of cocaine, physicians began prescribing cocaine to their patients who required pain relief.[1]

Unaware of Freud and Halsted's experiments with cocaine, American Physician W.H. Bentley was conducting his own similar experiments. The Index Medicus published his article describing how he successfully treated patients with cocaine who were addicted to opium and alcohol. In the late 1800s the use of cocaine as a recreational drug spread like a worldwide epidemic.[1]

As cocaine continued to spread physicians began looking for ways to treat patients with opium, cocaine, and alcohol addictions. Physicians debated the existence of the label 'addictive personality' but believed the qualities Freud possessed (bold risk taking, emotional scar tissue, and psychic turmoil) were of those that fostered the 'addictive personality'.[1]

Important contributors

Physician, Sigmund Freud, born on May 6, 1856 in Freiberg, Moravia (an area now known as Pribor in the Czech Republic) was instrumental in the field of psychology. Dream interpretation and psychoanalysis (also known as talk therapy) are two of his well known contributions. Psychoanalysis is used to treat a multitude of conditions including addictions.[2]

William Halsted born on September 23, 1852 in New York City, received his degree in medicine in 1877. Throughout his medical career as a surgeon he contributed surgical techniques that ultimately led to improvement of the patient's outcome following surgery. During Halsted's professional career, (along with Freud) conducted experiments with the drug cocaine. While their research was in process they became guinea pigs for their own experiments when they became addicted to cocaine. In 1884 he became the first to describe how cocaine could be utilized as a localized anesthetic when injecting into the trunk of a sensory nerve, and how the localized ischemia prolonged the anesthetic properties of the drug.[1][3]

G. Alan Marlatt was a pioneer in the field of addiction psychology. Born in Vancouver, British Columbia in 1941 he spent his professional career as an addiction psychologist, researcher, and director of the University of Washington's Addictive Behaviors Research Center and professor in the Department of Psychology. Marlatt adopted the theory of Harm reduction, developed and scientifically tested ways to prevent an addict's slip from becoming a relapse. He understood that by expecting immediate and complete abstinence from an addict often detered addicts from seeking the help they needed and deserved. Alan Marlatt died on March 14, 2011.[4][5][6]

A. Thomas McLellan was born in 1949 in Statan Island, NY. He is currently a professor at the University of Pennsylvania School of Medicine at the Center for Studies of Addiction. McLellan serves or has served on editorial boards as a reviewer of medical and scientific journals, and as an advisor to government and non-profit organizations including the National Practice Laboratory of the American Psychiatric Association, and the World Health Organization. He is co-founder and Chief Executive Officer of the Treatment Research Institute located in Philadelphia, PA. McLellan has conducted decades of research for the efficacy of treatment for substance abuse patients, and is recognized both at the national and international level as an addiction psychologist. He is also known for the development of the Addiction Severity Index or ASI and currently serves as Editor in Chief of the Journal of Substance Abuse Treatment and the Deputy Officer of National Drug Control Policy, Research and Evaluation;[7]

Arnold Washton Ph.D. has specialized in addiction since 1975 and is a world-renowned addiction psychologist known for his pioneering work in the development of therapeutic approaches to the treatment of drug and alcohol abuse. He is the author of many books and professional journal articles on treatment and addiction. He is a lecturer, clinician, researcher, and has served on the advisory committee for the US Food and Drug Administration. Dr Washton is founder and executive director of Recovery Options,a private addiction treatment practice located in New York City and Princeton, New Jersey.[8][9]

Addiction

Addiction is a progressive disease and psychiatric disorder that is defined by the American Society of Addiction Medicine as "a primary, chronic disease of brain reward, motivation, memory and related circuitry. It is characterized by the inability to control behavior, it creates a dysfunctional emotional response, and it affects the users ability to abstain from the substance or behavior consistently.[10] Psychology Today defines addiction as "a state that can occur when a person either consumes a substance such as nicotine, cocaine, or, alcohol or engages in an activity such as gambling or shopping/spending."[11]

When a non-addict takes a drug or performs a behavior for the first time he/she does not automatically become an addict. Over time the non-addict chooses to continue to engage in a behavior or ingest a substance because of the pleasure the non-addict receives. The now addict has lost the ability to choose or forego the behavior or substance and the behavior becomes a compulsive action. The change from non-addict to addict occurs largely from the effects of prolonged substance use and behavior activities on brain functioning. Addiction affects the brain circuits of reward and motivation, learning and memory, and the inhibitory control over behavior.[12]

There are different schools of thought regarding the terms dependence and addiction when referring to drugs and behaviors. One adopted belief is that "drug dependence" equals "addiction." The second belief is that the two terms do not equal each other. According to the DSM, the clinical criteria for "drug dependence" (or what we refer to as addiction) include compulsive drug use despite harmful consequences; inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter reflects physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs—including even appropriate, medically instructed use. Thus, physical dependence in and of itself does not constitute addiction, but often accompanies addiction. This distinction can be difficult to discern, particularly with prescribed pain medications, where the need for increasing dosages can represent tolerance or a worsening underlying problem, as opposed to the beginning of abuse or addiction.

There are some characteristics of addiction that regardless of the type share commonalities. The behavior provides a rapid and potent means of altering mood, thoughts, and sensations of a person which occur because of physiology and learned expectations. The immediate precipitating factors of the relapse, the timing of the relapse and the rate of relapse following treatment is high.

American Psychological Association

The American Psychological Association (APA) is a professional psychological organization and is the largest association of psychologists in the United States. Over 100,000 researchers, educators, clinicians and students support the association through their membership. Their mission "is to advance the creation, communication and application of psychological knowledge to benefit society and improve people's lives."[13]

APA supports 54 divisions, two of which pertain to addictions. Division 50, Society of Addiction Psychology promotes advances in research, professional training, and clinical practice within the range of addictive behaviors. Addictive behaviors include problematic use of alcohol, nicotine, and other drugs as well as disorders involving gambling, eating, spending, and sexual behavior.[14] Division 28, Psychopharmacolgy and Substance Abuse promotes teaching, research, and dissemination of information regarding the effects of drugs on behavior.[15]

The College of Professional Psychology (CPP), hosted by the American Psychological Association Practice Organization, previously offered a certificate to psychologists whom demonstrated proficiency in the psychological treatment of alcohol and other substance-related disorders. The CPP maintains the certificate of proficiency for persons who acquired it prior to 2011. The Society of Addiction Psychology certificate will be re-instated while the Society examines other avenues for credentialing professionals in addiction treatment.[16]

Addiction is not a "Disease"

40 years ago society was extremely judgmental towards people with addictions than they are now. Addicts were seen as abnormal and missing discipline and morality in their self-focused lives. When the idea of addiction being a disease was brought to life, people tended to not look so down on addicts. Addiction has very little in common with diseases. Addiction is behaviors and choices not an illness on its own. Addiction is self-acquired and is not transmissible, contagious, autoimmune, hereditary, degenerative, or traumatic. Diseases are illnesses, sicknesses, or ailments. Addiction is the symptom of the choice to use drugs and alcohol. Addiction is a choice, not a disease. Abstinence is the number one cure for addiction to drugs. There is no requirement for medical intervention to treat addiction, such as surgery. [17] [18] [19]

Addiction as a Disease

It seems that wherever one finds intoxication, one likely will find addiction.[20] Recently researchers have argued that the addiction process is like the disease model, with a target organ, a defect, and symptoms of the disease. In other accounts, addiction is a disorder of genes, reward, memory, stress, and choice.[21]

The Disease Model in Addiction

According to the new disease model, rather than being a disease in the conventional sense, addiction is a disease of choice. That is, it is a disorder of the parts of the brain necessary to make proper decisions. As one becomes addicted to cocaine, the ventral tegmentum nucleus accumbens in the brain is the organ.[22] The defect is stress-induced hedonic regulation.

Understanding the impact that genes, reward, memory, stress, and choice have on an individual will begin to explain the Disease Model of Addiction

Genetic

The genetic makeup of an individual determines how they respond to alcohol. What causes an individual to be more prone to addiction is their genetic makeup. For example, there are genetic differences in how people respond to methylphenidate (Ritalin) injections.[23]

Reward

Increased dopamine is correlated with increased pleasure. For that reason, dopamine plays a significant role in reinforcing experiences. It tells the brain the drug is better than expected. When an individual uses a drug, there may be a surge of dopamine in the midbrain, which can result in the shifting of that individual’s pleasure “threshold” (see figures one and two).[22]

Memory

The neurochemical, glutamate is the most abundant neurochemical in the brain. It is critical in memory consolidation. When an addict discovers an addicting behavior, glutamate plays a role by creating the drug cues. It is the neurochemical in motivation which initiates the drug seeking, thus creating the addiction.[24]

Stress

When under stress the brain is unable to achieve homeostasis. As a result the brain reverts to allostasis, which in turn alters the brains ability to process pleasure, which is experienced at the hedonic “set point” (see figures one).[25] Thus, previous pleasures may become no longer pleasurable. This is also known as anhedonia, or “pleasure deafness.” When stressed, the addict may experience extreme craving—an intense, emotional, obsessive experience.[20]

Choice

An addict may incur damage to the orbitofrontal cortex (OFC), the anterior cingulate cortex (ACC), and the prefrontal cortex (PFC). This damage causes a tendency to choose small and immediate rewards over larger but delayed rewards, deficits in social responding due to decreased awareness of social cues, and a failure of executive function such as sensitivity to consequences.[26]

Licensed Practitioners

Many degrees provide space for the treatment of addictions. The educational background that each professional obtains will contain similarities but the philosophy and the viewpoint from which the material is delivered may vary. The required amount of education prior to earning a certificate or degree also varies. A few of the more commonly recognized fields of study are included.[27]

Recognized Certifications in the Field of Addiction Psychology

Many certifications are recognized in the field of addiction psychology. Each have their own requirements.

Treatment

Both process addiction and behavioral addiction have many dimensions causing disarray in many aspects of the addicts' life. Treatment programs are not a one size fits all phenomenon, hence there are different modalities or levels of care. Effective treatment programs incorporate many components to address each dimension. The addict suffers from psychological dependence and some may suffer from physical dependence. Helping an individual stop using drugs is not enough. Addiction treatment must also help the individual maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Addiction is a disease which alters the structure and function of the brain. The brain circuitry may take months or years to recover after the addict has recovered. This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences. Research shows that most addicted individuals need a minimum of 3 months in treatment to significantly reduce or stop their drug use, however treatment in excess of 3 months has a greater success rate. Recovery from addiction is a longterm process.[30]

Modalities of Care

The modality or level of care needed for a patient is decided by the treating professional in conjunction with the patient when feasible. As expected the patient receiving treatment will likely take steps forward and backward the level of care will likely to fluctuate. Common modalities are explained.

Detoxification and Medically Managed Withdrawal

The process when the body rids itself of drugs is referred to as detoxification, and is usually concurrent with the side effects of withdrawal which vary depending on the substance(s) and are often unpleasant and even fatal. Physicians may prescribe a medication that will help decrease the withdrawal symptoms while the addict is receiving care in an inpatient or outpatient setting. Detoxification is generally considered a precursor to or a first stage of treatment because it is designed to manage the acute and potentially dangerous physiological effects of stopping drug use.[31][32]

Long-term Residential

Treatment is structured and operates 24 hours a day. Residents will remain in treatment from usually 6 to 12 months while developing accountability, responsibility and socialization skills. Activities are designed to help addicts recover from destructive behavior patterns while adopting positive behavioral patterns. Constructive methods of interacting with others and improving self-esteem are other areas of focus. The therapeutic community model is an example of one treatment approach. Many therapeutic communities provide a more comprehensive approach to include employment training and other support services.[32][33][34][35]

Short-term Residential

Short-term residential programs are on average 3–6 weeks in a residential setting. The program is intensive followed by more extended outpatient treatment to include individual and/or group therapy, 12-step Anonymous programs, or other forms of support. Because of the short duration of this modality it is even more important for individuals to remain active in outpatient treatment programs to help decrease the risk of relapse following residential treatment.[32]

Outpatient-treatment Programs

Outpatient treatment program vary regarding the services offered and the intensity. It's more affordable and may be more suitable for patients who are employed full-time and/or who have secured multiple social supports. Outpatient programs may include group and/or individual therapy, intensive outpatient program, and partial hospitalization. Some outpatient programs are also designed to treat patients with medical or other mental health problems in addition to their drug disorders.[32][36]

Individualized Drug Counseling

Individualized drug counseling not only focuses on reducing or stopping illicit drug or alcohol use; it also addresses related areas of impaired functioning such as employment status, illegal activity, and family/social relations as well as the content and structure of the patient's recovery program. Through its emphasis on short-term behavioral goals, individualized counseling helps the patient develop coping strategies and tools to abstain from drug use and maintain abstinence. The addiction counselor encourages 12-step participation (at least one or two times per week) and makes referrals for needed supplemental medical, psychiatric, employment, and other services.[32]

Group Counseling

An outpatient treatment option facilitated by a treatment provider and used to expand on the support system the patient already has. Groups foster a non-judgmental environment allowing patients to meet and discuss difficulties and successes of their addiction while providing on-going support that is needed to be successful with recovery.[32]

Intensive Outpatient Program (IOP)

As the name implies this is an outpatient treatment option designed for addicts who for various reasons do not have the opportunity to attend an inpatient treatment program, yet who otherwise would not be able to receive the level of support needed to recover from their addiction. Programs vary in duration based on the patients need. Because of the lower level of support offered IOP is frequently used as a step down approach from patients leaving inpatient treatment but who are still in need of intensive therapy.[32]

Prevention, Relapse & Recovery

Therapeutic Orientations & Approaches

In 1878 the Index Medicus published research conducted and written by American physician W.H. Bentley. Bentley's research described his success in treating patients addicted to the ‘opium habit’ w/cocaine. Two years later he reported success in treating both opium and alcohol abusers w/cocaine.[1] Today, the swapping one addiction for another is referred to as crossover addiction.[37]

A variety of treatment approaches are utilized by health professionals in order to provide their clients the highest possible level of success to overcome their addictions. There is no one specific approach and often therapists will use multiple techniques.

Further reading

References

  1. 1 2 3 4 5 6 Markel, Howard (July 2011). An Anatomy of Addiction. New York: Panthean. pp. 6–8, 31, 76. ISBN 978-1-4000-7879-0.
  2. ↑ About.com. "Sigmun Freud". About.com. Retrieved 3 November 2012.
  3. ↑ Olch, Dr. Peter D. (March 2006). "William Stewart Halsted". Annals of Surgery (Lippincott, Williams, and Wilkins) 243 (3): 418–25. doi:10.1097/01.sla.0000201546.94163.00. PMC 448951. Retrieved 3 November 2012.
  4. ↑ American Civil Liberties Union of Washington State (6 April 2011). "Remembering G. Alan Marlatt-Harm Reduction Pioneer". American Civil Liberties Union of Washington State. Retrieved 3 November 2012.
  5. ↑ Szalavitz, Maia (March 2011). "Appreciation: G. Alan Marlatt Brought Compassion to Addiction Treatment". Time Magazine. Retrieved 3 November 2012.
  6. ↑ Hevesi, Dennis (March 2011). "G.A. Marlatt, Advocate of Shift in Treating Addicts". New York Times. Retrieved 3 November 2012.
  7. ↑ United States Senate Committee on the Judiciary. "Deputy Director of National Drug Control Policy - A. Thomas McLellan". United States Senate Committee on the Judiciary. Retrieved 3 November 2012.
  8. ↑ Harper Collins. "Arnold M. Washton". Harper Collins. Retrieved 10 November 2012.
  9. ↑ "Dr. Arnold M. Washton". Retrieved 10 November 2012.
  10. ↑ Addiction Society of Addiction Medicine. "Addiction Society of Addiction Medicine". Addiction Society of Addiction Medicine. Retrieved September 13, 2011.
  11. ↑ Psychology Today. [(http://www.psychologytoday.com/basics/addiction) "Psychology Today"] Check |url= value (help). Psychology Today. Retrieved September 14, 2011.
  12. ↑ National Institute of Drug Abuse (2009) [1st edition 1999]. Principles of Drug Addiction Treatment: A research based guide (Second ed.). National Institute of Drug Abuse, NIH PUB #09-4180.
  13. ↑ American Psychological Association. "American Psychological Association". American Psychological Association. Retrieved 15 September 2012.
  14. ↑ Society of Addiction Psychology Division 50. "Society of Addiction Psychology Division 50". Society of Addiction Psychology Division 50. Retrieved 15 September 2012.
  15. ↑ Psychopharmacology and Substance Abuse Division 28. "Psychopharmacology and Substance Abuse Division 28". Psychopharmacology and Substance Abuse Division 28. Retrieved 15 September 2012.
  16. ↑ American College of Professional Psychology. "American College of Professional Psychology" (PDF). American College of Professional Psychology. Retrieved 15 September 2012.
  17. ↑ Dodds, L. (2011, December 17). The Heart of Addiction. Retrieved from https://psychologytoday,com/bbg/the-heart-of-addiction/201112/is-addiction-really-a-disease
  18. ↑ Holden, T. (2012, April 3). Addiction is not a disease. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314045/
  19. ↑ Schaler Ph.D., J. (2002). Addiction is a Choice. Open Court Publishing.
  20. 1 2 McCauley. K. (Producer) & Clegg, J. (2010) Pleasure Unwoven. [DVD]. Available from http://www.instituteforaddictionstudy.com/products.html
  21. ↑ Berridge, K. C.; Robinson, T. E. (1998). "What is the role of dopamine in reward: Hedonic impact, reward learning, or incentive salience?". Brain Research Reviews 28 (3): 309–369. doi:10.1016/S0165-0173(98)00019-8.
  22. 1 2 Olds, J., & Milner, P. (1954). P Journal of Comparative and Physiological Psychology, 47, 419-427.
  23. ↑ Mayfield, R. D.; Harris, R. A.; Schuckit, M. A. (2008). "Genetic factors influencing alcohol dependence". British Journal of Pharmacology 154 (2): 275–287. doi:10.1038/bjp.2008.88.
  24. ↑ Hyman, S. E.; Malenka, R. C.; Nestler, E. J. (2006). "Neural mechanisms of addiction: the role of reward-related learning and memory". Annual Review of Neuroscience 29: 565–598. doi:10.1146/annurev.neuro.29.051605.113009. PMID 16776597.
  25. ↑ Koob, G., & Le Moal, M. (2001). Drug addiction, dysregulation of reward, and allostasis. " Neuropsychopharmacology 24(2), 97-120. Retrieved from http://dionysus.psych.wisc.edu/CourseWebsites/PSY411/Articles/KoobG2001a.pdf
  26. ↑ Kalivas, P. W., & Volkow, N. D. (2005). The neural basis of addiction: A Pathology of Motivation and Choice. The American Journal Of Psychiatry,162(8), 1403-1413
  27. ↑ British Psychological Society. "Types of Psychologists-'Related Fields'". British Psychological Society. Retrieved 24 October 2012.
  28. 1 2 3 4 5 6 Psychology Today. "Psychology Today Therapy Directory". Psychology Today. Retrieved 16 September 2012.
  29. ↑ "Jeremy Frank Ph.D., Philadelphia Psychologist - Addiction Counselor". Retrieved 19 April 2013.
  30. ↑ National Institute on Drug Abuse (1999). Principles of Drug Addiction Treatment. National Institute on Drug Abuse.
  31. ↑ Kleber, H.D. (1996). "Outpatient detoxification from opiates". Primary Psychiatry 1: 42–52.
  32. 1 2 3 4 5 6 7 National Institute on Drug Abuse (April 2009). Principles of Drug Addiction Treatment: A Research Based Guide, Pub number 09-4180 (Second ed.). Diane Publishing.
  33. ↑ Tims, Frank M.; Jainchill, Nancy, De Leon, George (1994). "Therapeutic Communities and Treatment Research". National Institute on Drug Abuse Research Monograph (144): 162–180. NIH Pub No. 94-3633. Retrieved 14 November 2012.
  34. ↑ Inciardi, James A.; Tims, Frank M.; et al. (1993). Inciardi, James A., Frank M. Tims, Fletcher, Bennett W., ed. Innovative Approaches in the Treatment of Drug Abuse: Program Models and Strategies. Westport, CT: Greenwood Press. pp. 45–60.
  35. ↑ Sacks, S.; Banks, S, McKendrick, K., Sacks, J.Y. (2008). "Modified Therapeutic Community for Co-occurring Disorders: A summary of Four Studies". Journal of Substance Abuse Treatment 34 (1): 112–122. doi:10.1016/j.jsat.2007.02.008.
  36. ↑ Mclellan, A.T.; Grisson, G.; Durell J.; Alterman, A.I.; Brill, P.; O'Brien, C.P. (1993). "Substance Abuse Treatment in the Private Setting: Are some programs more effective than others?". Journal of Substance Abuse Treatment 10 (3): 243–254. doi:10.1016/0740-5472(93)90071-9. PMID 8391086.
  37. ↑ Behavioral Medicine Associates. "The Addictive Process". Psychiatry and Wellness:Behavioral Medicine Associates. Retrieved 24 October 2012.
  38. 1 2 Cherry, Kendra. "The Rise of Behaviorism". About.com. Retrieved 10 November 2012.
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  43. ↑ Beck, Judith (2011). Cognitive Behavioral Therapy: Basics and Beyond (second ed.). New York: Guilford Press. pp. 2–10. ISBN 978-1609185046.
  44. ↑ Mayo Clinic staff. "Cognitive Behavioral Therapy". Mayo Clinic. Retrieved 3 October 2012.
  45. ↑ "Cognitive Behavioral Therapy". National Association of Cognitive- Behavioral Threrapists. Retrieved 3 October 2012.
  46. ↑ Hartney, Elizabeth (3 March 2011). "Cognitive Behavioral Therapy for Addictions". About.com. Retrieved 10 November 2012.
  47. ↑ Pederson, Lane; Sidwell, Cortney Pederson (2012). The Expanded Dialectical Behavior Therapy Skills Training Manual. Wisconsin: Premier Publishing and Media. ISBN 978-1-936128-12-9.
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  49. ↑ "International Expressive Arts Therapy Association". International Expressive Arts Therapy Association. Retrieved 30 September 2012.
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  51. 1 2 3 Dr. Jeremy Frank, Ph.D. "Harm Reduction". Retrieved 5 October 2012.
  52. 1 2 3 4 5 Marlatt, PhD, Alan G.; Larimer, PhD, Mary E. (2012). Marlatt, PhD, Alan G., ed. Harm Reduction: Pragmatic Strategies for Managing High Risk Behaviors (Second ed.). New York, New York: The Guilford Press. pp. 147–48, 151. ISBN 978-1-4625-0256-1.
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  54. ↑ Marlatt, P.hD. Alan G. (November–December 1996). "Harm reduction: come as you are". Journal of Addictive Behaviors 21 (6): 779–88. doi:10.1016/0306-4603(96)00042-1. ISSN 0306-4603. PMID 8904943.
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  56. ↑ "Types of Therapies". CRC Health Group. Retrieved 30 September 2012.
  57. ↑ Horowitz, Sala (December 2010). "Animal Assisted Therapies for Inpatients:Tapping the Unique Healing Power of the Human -Animal Bond". Alternative and Complimentary Therapies 16 (6): 339–343. doi:10.1089/act.2010.16603.
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