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Any treatment modality or style needs to deal with the fact that Al is confronted with a close co-worker who is a cocaine user. In 12-step每oriented treatment, this situation would be referred to as one of those "persons, places, and things" that threaten sobriety. In cognitive-behavioral relapse prevention, this would be a "high-risk situation" that may serve as a "trigger." Offers of drugs from such persons, particularly if the drug itself or paraphernalia are waved under the patient's nose, may likely produce powerful cravings and lead to lapse or relapse. Patients are generally encouraged to avoid such situations, and relapse prevention therapy teaches various skills both for avoidance and for coping when confronted with the situation. A co-worker can be particularly hard to avoid. Cash businesses, such as Al's restaurant business, can also be set-ups for relapse, and cash itself "in the pocket" can also become a powerful trigger for drug use. Sometimes a co-worker can be confronted by a patient and asked to cease and desist. As Al is apparently the boss, he may be in a good position to do so. Sometimes the offending co-worker can be successfully shunned. Regarding money, it is often helpful to have someone else handle it, so that it is not "burning a hole" in the patient's pocket. In any case, his therapist would need to help Al problem solve these issues.
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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 ) y- N0 U1 `# \' W( s
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Bien TH, Miller WR, Tonigan JS: Brief interventions for alcohol problems: a review. Addiction 88:315每335, 1993  [PubMed]
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1 V1 N; a- L: V  G& vCarroll KM, Rounsaville BJ, Nich C, et al: One-year follow-up of psychotherapy and pharmacotherapy for cocaine dependence: delayed emergence of psychotherapy effects. Arch Gen Psychiatry 51:989每997, 1994  [PubMed] . s, f8 O2 A; ?  A
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Crits-Christoph P, Siqueland L, Blaine J, et al: Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry 56(6):493每502, 1999
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9 d; Q! N9 e& r1 K9 }& W; dKadden RM: Project MATCH: treatment main effects and matching results. Alcohol Clin Exp Res 20(suppl 8):196A每197A, 1996 # W. M0 z3 m/ z' ~/ y- s6 G
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Liddle HA, Dakof GA, Parker K, et al: Multidimensional family therapy for adolescent drug abuse: results of a randomized clinical trial. Am J Drug Alcohol Abuse 27(4):651每688, 2001
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6 M2 s2 ^- L; a* l, g& bMiller WR, Rollnick S: Motivational Interviewing: Preparing People for Change, 2nd Edition. New York, Guilford Press, 2002
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Nunes EV, Quitkin FM: Treatment of depression in drug dependent patients: effects on mood and drug use. NIDA Res Monogr 172:61每85, 1997  [PubMed]   I% v* \3 y! k

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Child Psychiatrist, with treatment discussion
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DSM-IV-TR Casebook Diagnosis of "Child Psychiatrist") z( H6 N' s" I- G
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Dr. Crone experiences recurrent intense sexual urges and sexually arousing fantasies involving sexual activity with prepubescent boys. He has acted on these fantasies and urges on many occasions. This alone is sufficient to make the diagnosis of Pedophilia (see DSM-IV-TR). The diagnosis would also be made if Dr. Crone had never acted on these fantasies and urges but was markedly distressed by them or if they caused interpersonal difficulties.
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) O* H0 V) z& Y6 |9 W) fDiscussion of "Child Psychiatrist" by Fred S. Berlin, M.D., Ph.D.*
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A psychiatric diagnosis is simply a shorthand way of conveying useful information. The term pedophilia denotes that an individual's sexual orientation (usually a male's) is directed either in whole or in part toward prepubescent children. Thus, although Dr. Crone has been diagnosed with Pedophilia, contrary to what some might believe, the term conveys no information whatsoever about his character, temperament, honesty, integrity, attitudes, or intellectual level, nor does it convey any information about either the presence or absence of additional Axis I or Axis II comorbid conditions. The fundamental treatment focus in working with him must be directed toward his disordered sexuality, rather than toward more peripheral concerns (Berlin and Krout 1986). In the course of treating Dr. Crone, it will also be important to determine whether any comorbid conditions, such as depression, personality disorder, or alcoholism, are present, and, if so, to treat them as well.% @5 N$ T$ f) M" I& R
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The public often uses the term pedophilia as a stigmatizing pejorative label, and persons with the condition are frequently portrayed as subhuman predators. In point of fact, persons with pedophilia can differ from one another in the expression of their sexuality, just as individuals whose sexual orientation is directed toward adults do. Whereas some persons with pedophilia may simply feel a sense of lust, many, as seems likely in Dr. Crone's case, enjoy the companionship of children and have a genuine affection for them (Money 1980). Usually, the issue is not a lack of concern for them but a sexual attraction to them, which, if enacted, can damage what, in other ways, may have been a caring relationship. In therapy, I would reassure Dr. Crone that I had an appreciation of that fact. At the same time, he must appreciate why such behavior is criminal.
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In treating a patient such as Dr. Crone, it is important to recognize that he has not simply chosen to experience sexual attraction to young boys. As youngsters, none of us paused to weigh our options, deciding whether to grow up to be attracted either to women, men, girls, or boys. Likely, no one would choose to develop a sexual orientation that is directed toward prepubescent youngsters〞and neither did Dr. Crone. One known etiological risk factor for the development of pedophilia is having been sexually abused during childhood, and Dr. Crone, like many men with the disorder, is indeed a former victim (Freund and Kuban 1994). This too, will likely need to be addressed in his treatment.. x6 a5 k+ `$ p2 |
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Historically, there have been a number of misconceptions about pedophilia that have sometimes led to misdirected treatments〞treatments that should be avoided in this instance. For example, some have speculated that pedophilic behavior is more about power and control than about sexuality. Others have suggested that persons with the disorder turn to children because they lack the maturity, confidence, and social skills necessary to attract other adults. However, neither of these formulations can explain why it is that Dr. Crone can ordinarily get an erection only in response to fantasies about prepubescent boys. Teaching him social skills might only serve to enhance his capacity to interact more successfully with children, and therefore I would not consider that to be either a necessary or an appropriate component of his care.6 Q9 U8 B6 s2 V- S& ^

/ _' k0 U- r  W5 SEarly psychodynamic theories postulated that pedophilia develops when something has gone wrong during the formative childhood maturation process (Freud 1985). Through subsequent therapy, one could develop insight regarding the etiology of the problem, thereby leading to a cure. Were a therapist to consider an individual such as Dr. Crone to have been cured, presumably it would then be safe for him to be around children. Sadly, in the past, many therapists have endorsed such an option. On the other hand, if part of Dr. Crone's treatment requires that he make every effort to avoid situations of temptation that he may not be capable of handling, then he should refrain from any unnecessary contacts with youngsters. Pedophilia is a chronic disorder that cannot be cured, and successful treatment, with a primary goal of abstinence from any and all sexual contacts with children, requires that the individual being treated not place himself in circumstances in which he is vulnerable or "tempted" (Fagan et al. 2002). Insight-oriented psychotherapy is not the treatment of choice for pedophilia, and Dr. Crone should be informed that maintaining proper behavioral control, rather than insight about the etiology of his condition, is the primary goal of his treatment.
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