List and describe the nine principles of the CENAPS Model of Relapse Prevention. Use the Module 6 Notes to assist you.Discuss the six stages of the Developmental Model of Recovery outlined in the mod

DAAC 1319: Intro to AOD

Module Six Notes

Module Six

Relapse Prevention

This module looks at the role of Twelve-Step Programs and other forms of self-help groups in the treatment and aftercare of clients with substance use disorders. In studying relapse prevention, a critical component of effective treatment, we will explore in depth the six stages of the Developmental Model of Recovery.

Self-Help Groups

All twelve-step programs were born out of the shadow of Alcoholics Anonymous (AA). AA was founded in 1935, by Bill Wilson, a stockbroker and Dr. Bob Smith “Dr. Bob”, a surgeon. The text book does an excellent job of providing an overview of both the 12 Steps of AA and the 12 Traditions. Most twelve-step programs follow the same steps with minor adjustments. The primary goal of A.A. is for the individual to maintain sobriety. The only requirement to join A.A. is a desire to stop drinking. There are no dues or fees for membership; there is no set number of meetings to attend. The leadership of local meetings rotates to different members who serve the group for a specific period of time (1-3 months typically). Typical positions include: a chairperson, a secretary, a treasurer, program committee, food committee, and general service representative to the region. Newcomers with good sobriety are encouraged to take on responsibilities in the group. A.A. is not a religious group and welcomes persons of all belief systems or those with none. The principles of A.A. do not conflict with any religious beliefs. A.A. is a spiritual program that allows members to interpret its principles in a way that makes sense to them.

A typical meeting has a chairperson who opens and closes the meeting. There are several types of meetings: speaker meeting where one individual tells his/her story of addiction and recovery which enables the listeners to identify with them and not feel alone, gain hope that they too can achieve sobriety and learn new ways of thinking and handling situations in their life. Another type of meeting is a speaker-discussion meeting, in addition to hearing a speaker; the other members have the opportunity to share comments and reactions to the talk. This allows members to show that they identify with and appreciate the speaker. A third type of meeting is a discussion meeting - a topic is chosen for the meeting and members share their thoughts and feelings. This allows members to:

hear new ideas and approaches; put thoughts into words and receive feedback from other members and actively participate in the meeting. A fourth type of meeting is a step meeting, this is a discussion meeting which takes focuses on one or all of the 12 steps. Meetings may be either open or closed. Open meeting - are open to anyone interested in attending, the only requirement is to not disclose member's names outside the meeting. Closed meeting - are open only to alcoholics

A.A.'s approach is to maintain sobriety for 24 hours. This makes not drinking more manageable than looking toward no drinking for a lifetime which is overwhelming. The focus is "here and now" - not "yesterday or tomorrow". Sponsorship is a critical component of the effectiveness of the twelve step movement. A newly recovering member is encouraged to select a more experienced member with good sobriety as their sponsor. The sponsor will act as a guide and confidant during the early period when the alcoholic needs one person to turn to for help in sorting out the confusion, to encourage attendance at meetings, to introduce the newly recovering alcoholic to other A.A. members, to explain the workings of A.A., and to be available during a crisis. The new member is encouraged to ask for telephone numbers of other members in order to stay in touch between meetings. Phone contact ensures that help is available 24 hours a day in case the alcoholic fears he/she will drink again. Telephone contact is another way to break the isolation that surrounds the newly recovering alcoholic.

According to AA, a slip is a recurrence of drinking after a period of abstinence. I may occur soon after sobriety or years later. Slips occur when the alcoholic: forgets the amount of trouble alcohol has caused, becomes overconfident in their ability to deal with alcohol, becomes too busy to attend to personal needs and becomes “HALT” (hungry, angry, lonely, and tired), stays away from A.A. meetings or A.A. friends. According to AA slips don't just happen - they are part of the illness and the result of not following a good program of sobriety.

AA literature includes:

1. Alcoholics Anonymous - The Big Book

a. Stories of people who recovered through A.A. which are inspiring to others

b. Steps and principles that help recovery

2. Twelve Steps and Twelve Traditions - an explanation of the steps and traditions of A.A.

3. As Bill Sees It - the writings of Bill Wilson, one of the co-founders of A.A.

4. Pamphlets

a. Available at meetings

b. Covers many topics relating to recovery from alcoholism

New members are encouraged during the first year to associate with the same sex members in order to prevent the development of male-female relationships during early recovery because: the focus will be shifted from recovery to intimacy, the emotions of a new relationship are difficult to handle in early recovery, the alcoholic needs to allow time to recover physically and work through emotional issues before being ready for an intimate relationship with the opposite sex.

In reviewing the Twelve Steps, it becomes apparent that they are a guide to not only living sober, but to developing an effective outlook on life in general:

1. "We admitted we were powerless over alcohol - that our lives had become unmanageable.”

This is recognition that willpower cannot cure alcoholism, and that alcohol is the source of the problems in an alcoholic's life.

2. "Came to believe that a power greater than ourselves could restore us to sanity.”

Since alcohol created such distortion in thinking, the alcoholic cannot rely on themselves to know what is best. They must turn to someone else, some turn to other AA members or counselors for guidance, some turn to a Higher Power.

3. "Made a decision to turn our will and our lives over to the care of God as we understood Him."

This shows acceptance of a source greater than oneself who will help the recovery process and a willingness to do what others suggest in order to recover. Higher power does not necessarily mean a Divine God; it can mean a human being who is living a sober, healthy life, the goodness in oneself, the A.A. group, or a Divine God. As an alcoholic grows in recovery, the concept of higher power grows with them and usually causes less trouble.

4. "Made a searching and fearless moral inventory of ourselves."

The inventory is the beginning of self-assessment; it identifies strengths to draw upon in the recovery process. The inventory pinpoints weaknesses to address so they don't become stumbling blocks in recovery.

5. "Admitted to God, to ourselves, and to another human being the exact nature of our wrongs."

Admitting wrongs to oneself is a way of honestly recognizing that the alcoholic has made a mess of their life. Admitting wrongs to another is a way of making the faults and mistakes more real because someone else has heard them. This is also a way of beginning to accept oneself because the other person is still accepting of the alcoholic in spite of the wrong-doings. Admitting wrongs to God is a way of apologizing to the highest source.

6. "Were entirely ready to have God remove all these defects of character."

They are now ready to begin the work of correcting them. They turn to God for help - God will provide the strength and opportunities to work on the faults.

7. "Humbly asked Him to remove our shortcomings."

This means doing the work, one small action at a time, to correct the faults while relying on God for strength and opportunities. Recovering alcoholics do not expect God to miraculously wipe out old faults but provide the guidance to do so.

8. "Made a list of all persons we had harmed and became willing to make amends to them all."

This involves listing all the people; including oneself that the alcoholic has harmed requires them to take responsibility for their actions.

9. "Made direct amends to such people whenever possible, except when to do so would injure them or others."

Making amends does not necessarily mean saying "I'm sorry"; it may mean changing behaviors and attitudes to those that are more responsible and healthy so that the lives of others will be made more positive.

10. "Continued to take personal inventory and when we were wrong promptly admitted it."

Taking periodic personal assessments helps the alcoholic remain on track. Promptly admitting errors prevents dangerous guilt, excuse making, blaming, and resentments which can lead to a resumption of drinking.

1. "Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out."

In seeking contact with God, the alcoholic comes to trust Him and know that He wants only good things for His creation. When the trust has been developed, it is easier to ask for His will because the alcoholic knows it will be for their own good and they will want to do it.

1. "Having had a spiritual awakening as a result of these steps, we tried to carry this message to others, and to practice these principles in all our affairs"

As the alcoholic practices these steps, they become healthy, sober individuals who are grateful for a chance to live without alcohol This gratitude and trust in the 12-Step recovery program prompts the alcoholic to share with other people who are still in the grips of alcoholism Sharing with others, a giving of self, is part of paying back a group who selflessly gave to them in time of need and a reminder of the consequences of not following the program.

The Twelve Traditions of A.A. guide membership activity:

1. "Our common welfare should come first; personal recovery depends on A.A. unity."

The good of the group is placed before individual gain. Splinter groups or schism would destroy the safety of A.A.

1. "For our group purpose there is but one ultimate authority- a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants - they do not govern.”

No one member is more important than another. Since A.A. is a spiritual program, the members seek to be well informed on issues and then let their higher powers lead them in a discussion of a problem, so that alternative solutions can be found. To prevent power grappling, the leadership rotates among members and all who maintain good sobriety have an equal chance at leadership

1. "The only requirement for A.A. membership is the desire to stop drinking."

This statement eliminates all the fuss that could arise about who is eligible to join A.A.

1. "Each group should be autonomous except in matters affecting other groups or A.A. as a whole."

Local internal affairs are handled best by those who are most affected - the local members. However, some issues and decisions are larger than just the local group, in which case cooperation with the groups and/or bringing the issues to regional or national A.A. boards can bring resolution.

1. "Each group has but one primary purpose - to carry its message to the alcoholic who still suffers."

A.A.'s only focus is recovery from alcoholism.

1. "An A.A. group ought never endorse, finance or lend the A.A. Name to any related facility or outside enterprise, lest problems of money, property and prestige divert us from our primary purpose."

A.A. never provides individuals or organizations with financial support. Individual or organization may hold beliefs that contradict A.A. principles creating public controversy. A.A. has no desire to accumulate material possessions.

1. "Every A.A. group ought to be fully self-supporting, declining outside contributions."

In this way A.A. is not beholden to anyone and can function autonomously.

1. "Alcoholics Anonymous should forever remain nonprofessional, but our service centers may employ special workers."

A nonprofessional status enables all members to give of their talents, not just the most intelligent or most skillful. The service centers do hire paid office staff

1. "A.A. as such, ought never to be organized; but we may create service boards or committees directly responsible to those they serve."

The intention is to prevent the development of a bureaucracy or the attainment of personal power.

1. "Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never to be drawn into public controversy."

The intention is to preserve A.A.'s unity with its sole focus on recovery from alcoholism. Supporting diverse interest will fracture the group, create friction, and destroy the safety needed for recovery

1. "Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films."

Attraction is an invitation to accept the help that is being offered; promotion is high pressure sales which has a flavor of self-interest. Anonymity ensures that A.A., not the individual, will receive attention

1. "Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities."

Anonymity provides protection against misunderstanding and condemnation by society. It also allows members to put aside their public images which are associated with their names and concentrate on working the principles of the program.

The 12-step recovery program of A.A. is used as the basis for other self-help groups such as Al-Anon. The primary purpose of Al-non is to offer support to the non-alcoholic in coping with the alcoholism of others. Al-Anon is open to relatives and friends of alcoholics the only requirement necessary to join Al-Anon is that there be an alcoholism problem with a relative or friend. The steps and traditions of Al-Anon are based on those of A.A. The meetings tend to be discussion or step meetings. Al-Anon teaches its members to accept that they cannot control the drinker and to realize they can love the alcoholic but do not need to let him/her control their lives any longer, i.e. detachment. They are encouraged to realize they are responsible for their own lives despite living with an alcoholic, to practice "tough love", i.e. continuing to love the alcoholic but refusing to cover up, soften the consequences of drinking, or be controlled by alcoholic behavior. Through "tough love", some alcoholics realize the need for treatment because the pain of the consequences of drinking becomes too great.

The primary purpose of Alateen is to offer support in dealing with alcoholism to the teenage children of alcoholics. The only requirement necessary to join Alateen is that there an alcoholism problem with a parent. Alateen is part of the Al-Anon Family groups. Each Alateen group must have the sponsorship of an Al-Anon member or an experienced Alateen member. The sponsor helps to lead discussions and is available during a crisis. Alateen teaches its members messages similar to those of Al- Anon: to accept that they have no control over the drinker, to be responsible for their own lives, and to practice "tough love".

The primary purpose of Adult Children of Alcoholics A.C.O.A. is to help adults who grew up in alcoholic or other dysfunctional homes to resolve the past hurts and angers that their childhood created. The group allows a grieving process to take place. The goal is healthy, functioning adults who are no longer controlled by the past. The only requirement necessary to join A.C.O.A. is that the member came from an alcoholic or dysfunctional family. The steps and traditions of A.C.O.A. are based on those of A.A. The meetings are discussion or step meetings. A.C.O.A. teaches its members to: accept that current problems are due to growing up in a dysfunctional family, handle the pain, anger, and sadness of a dysfunctional childhood, go through the grieving process to free themselves of the past, and realize that they are responsible for their lives today, regardless of the past.

The primary purpose of Narcotics Anonymous (N.A.) is to help its members stay drug-free. The only requirement necessary to join N.A. is the desire to stop using drugs. The steps and traditions of N.A. are based on those of A.A. The primary purpose of Nar-Anon is to offer support to family and friends of drug users to help them cope. The only requirement necessary to join Nar-Anon is that someone close to the member has a drug problem. The steps and traditions of Nar-Anon are based on those of A.A. Nar-Anon teaches its members to: accept that they have no control over the drug user, become responsible for their own lives, and create a health environment for their children.

Advantages and Disadvantages of Twelve-Step Groups

When we study group process in Module Eight, you will learn about the therapeutic value of group. Many of the advantages of Twelve-Step groups include these factors. These groups provide a since of belonging for individuals in an environment that is non-judgmental. They are a homogeneous group which allows for sharing and understanding; they provide opportunities for learning from the experiences of others, reality testing, and opportunities for altruistic acts. The since of universality that is felt by members helps them to understand that they are not alone. The spirituality component of the Twelve-Step movement has served as both an advantage and disadvantage in that it is often misunderstood and seen as a limitation in working with certain clients. Twelve-Step groups have tended to appeal mostly to middle-aged white married males. This has created environments which may not have the ability to address the needs of women and individuals of other cultural/racial backgrounds. This is slowly changing. Twelve-Step programs have also unfortunately been misunderstood by the judicial system. Some courts order individuals to attend AA instead of going to treatment. AA is not treatment and should be seen as an integral part of treatment but not a replacement for it.

Rational Recovery

Rational Recovery (RR) was founded in 1986 by Jack and Lois Trimpey in response to what they felt was a lack of choice in the field of addictions. RR was developed to provide an alternative for individuals whose needs were not being met by AA. Visit the following web sites to learn more about Rational Recover and Addictive Voice Recognition Technique (AVRT):

www.wsc.edu/student/services/counseling/alcohol/Commit.htm

www.peele.net/faq/avr.html

http://rational.org/Recovery/Crash.html

http://rational.org/

For additional information on Women for Sobriety write: P.O. Box 618, Quakertown, PA 18951.

For additional information on Secular Organization for Sobriety (SOS) visit:

www.stillwatermall.com/sos/

www.alcoholismhelp.com/help/editor/072098.html

The Developmental Model of Recovery

The Center for Substance Abuse Treatment (CSAT) has developed Technical Assistance Publication (TAP) 19: Counselor’s Manual for Relapse Prevention with Chemically Dependent Criminal Offenders @ www.treatment.org/TAPS/. While this manual was developed for clients who are in the criminal justice system it does a wonderful job of discussing the Developmental Model of Recovery which is a relapse prevention program. If you are in the online version of this course you can visit the web site to print off a copy of the manual. If you are in the classroom version of the course a copy of the manual is provided as an appendix in your Learning Guide. You will need to read this TAP in order to complete this module.

Counselor's Manual for Relapse Prevention with Chemically Dependent Criminal Offenders

Technical Assistance Publication Series 19

This publication is intended for use by people who are interested in working with criminal offenders who are chemically dependent (addicted to alcohol and/or drugs). It focuses on chemical dependency and the criminal offender, and will present you with information you may not have been exposed to before.

Research tells us that most criminal offenders have alcohol or drug problems. It also tells us that traditional forms of treatment for chemical dependency are not very successful with these offenders. Many of them return to using alcohol or drugs after treatment. When this happens, most of them become repeat offenders. This publication is designed to help you teach criminal offenders how they can stay sober and clean.

This publication is designed for the paraprofessional counselor. A paraprofessional counselor is someone who wants to help others, but who has little or no professional counselor training. This publication explains basic counseling information in simple terms.

This publication is based on information that has had better than average results in treating chemically dependent criminal offenders. This information is called relapse prevention therapy. Relapse prevention therapy is based on experience with patients who generally fail in traditional treatment. The techniques in this publication were developed through experience with these patients.

Relapse prevention therapy breaks down the recovery process into specific tasks and skills. Patients must learn these skills in order to recover. It also shows patients how to recognize when they are beginning to relapse, and how to change before they start using alcohol or drugs again.

How will you know when patients are making progress? You will know by seeing how they change the way they think, feel, and act toward themselves and others. If you try to control your patients, they will either drop out of treatment or simply manipulate you by telling you what they think you want to hear.

It is important that you view your patients as people whose disease of chemical dependency and way of thinking prevent them from acting in a socially acceptable manner. These patients may want to be full members of society, but they do not have the skills to do so. In some cases, they have given up hope.

It is your job to help your patients understand more about themselves and the world, help them learn new skills, and give them hope, so that they are motivated to change. You cannot do this by telling them what they are or what they must be. It is one thing for you to know, but unless the patient comes to an understanding based on changes in his or her own thinking, treatment will fail.

You do not have all the answers. Even professional counselors do not have all the answers. Most answers come from listening carefully to what patients say and how they think. If you do not know something, be honest. Patients will respect you for this and be more willing to work with you if you are honest about what you do and don't know. When you don't know an answer, try to find the information and share it with the patient.

Most of all, give patients your best effort. If you do this and learn from your mistakes, you will become a better counselor. Read as much as possible about chemical dependency and counseling for chemically dependent people. Get all the training you can. Remember, your best source of information is your patients. When you make a mistake, admit it and learn from it. Even if you

don't succeed with one patient; what you will learn will help other patients in the future.

You may never know for sure if you have helped most of your patients. Some patients will not use information you give them now, but will use it at some point in the future. Also, remember that every patient you help will have a positive impact on everyone with whom they come in contact.

What is Chemical Dependency/Addiction?

Chemical dependency is a disease caused by the use of alcohol and/ or drugs, causing changes in a person's body, mind, and behavior. As a result of the disease of chemical dependency, people are unable to control the use of alcohol and/or drugs, despite the bad things that happen when they use. Chemical dependency occurs most frequently in people who have a family history of the disease. As the disease process progresses, recovery becomes more difficult. Chemical dependency may cause death if the person does not completely abstain from using alcohol and other mood‑altering drugs.

Effects

The problems of chemical dependency that affect people when they use alcohol or drugs, and even after they have stopped using, include the following. Malnutrition and metabolic dysfunction. The addict's ability to function normally is damaged by the effects of alcohol and/or drugs on the brain and body. Only after a period of proper diet and taking supplements can normal body chemistry be restored. This process affects the way the addict thinks, feels, and acts. Liver disease and other medical complications. The addict's liver enzymes may be far above normal. This can cause poisonous effects within the body and may lead to infections and illnesses that need to be treated before normal functioning can resume. Brain dysfunction. Alcohol and drugs damage brain cells interrupt the production of certain brain chemicals called neurotransmitters, and alter the way the brain functions. Some of these changes may be permanent.

Addictive preoccupation. A chemically dependent person's thinking patterns are altered by chemical dependency as the disease progresses. These changes cause the person to have strong thoughts, desires, and physical cravings for alcohol or drugs. These processes also change the way the person sees the world. They lead the person to believe that using is better than not using, despite the bad things that result from using.

Social consequences. As the physical and psychological problems identified above get worse, the person's behavior becomes more antisocial and self‑destructive. Frequent social consequences of addiction are job loss, money problems, car accidents, domestic violence, criminal behaviors, illness, and death.

Criminal behaviors. Chemical dependency can cause a person to commit crimes. People who are chemically dependent commit crimes related to their use of alcohol or drugs (drunk driving, public drunkenness, assault, etc.), the support of their addiction (selling drugs, committing crimes to get drugs or money for drugs, etc.), and secondary consequences of drug or alcohol use (not paying child support or court fines, failing to follow through with probation requirements, etc.). Some people do not commit crimes until they become chemically dependent. Others have personality problems that initiate their criminal behavior. Most of those who have personality problems either become chemically dependent on or abusive of alcohol and drugs. Any relapse into behavior that leads to criminal actions is likely to cause a relapse into the use of alcohol or drugs. Any relapse into chemical use is likely to cause a relapse into criminal behavior.

The conditions just described combine and interfere with the ability to think clearly, control feelings, and regulate behaviors, especially under stress. Alcohol and drug dependency damages the basic personality traits that are formed before the addictive use of alcohol or drugs. Dependency on alcohol or other drugs systemically destroys meaning and purpose in life as the addiction gets worse and worse.

Treatment

Because dependency on alcohol or other drugs creates problems in a person's physical, psychological, and social functioning, treatment must be designed to work in all three areas. The worse the damage in each area, the greater the chance of relapse and return to old behaviors (criminal actions and/or the use of alcohol or drugs). Total abstinence (not using any alcohol and drugs) plus personality and lifestyle changes are essential for full recovery. The type and intensity of treatment depend on the patient's:

• Current physical, psychological and social problems

• Stage and type of addiction(s)

• Stage of recovery

• Personality traits and social skills before the onset of addiction

• Other factors in life that cause stress.

Chemical dependency is a chronic condition that has a tendency toward relapse. Abstinence from alcohol and other mood‑altering drugs is essential in the treatment of chemical dependency. It is also an important part of relapse prevention therapy. There is no convincing evidence that controlled drinking or drug use is a practical treatment goal for people who have been physically dependent on alcohol or drugs.

Many chemically dependent people who exhibit criminal behaviors were raised in families that did not provide proper support, guidance, and values. This caused them to develop self‑defeating personality styles that interfere with their ability to recover. Personality is the habitual way of thinking, feeling, acting, and relating to others that develops in childhood and continues in adult

life. Personality develops as a result of an interaction between genetically inherited traits and family environment.

Growing up in a dysfunctional family causes a person to have a distorted view of the world. He or she learns coping methods that may be unacceptable in society. In addition, the family may not have been able to provide guidance or foster the development of social and occupational skills that allow the person to fully participate in society. This lack of skills and distorted personality functioning may cause addictive behaviors to occur. These problems may also contribute to a more rapid progression of the addiction, make it difficult to recognize and seek treatment during the early stages of the addiction, and make it hard to benefit from treatment.

There are four goals in the primary treatment of dependency on alcohol and other drugs:

• Recognition that chemical dependency is a bio/psycho/social disease

• Recognition of the need for life‑long abstinence from all mind‑altering drugs

• Development and use of an ongoing recovery program to maintain abstinence

• Diagnosis and treatment of other problems or conditions that can interfere with recovery.

Traditional treatment has taken one of two general approaches:

• The Medical Model. This approach tries to help the patient meet the first three goals listed above.

• The Social/Behavioral Model. This approach focuses on the fourth goal listed above.

The lack of a model that includes all of the components has led to high relapse rates, especially in criminal justice populations. Relapse prevention therapy is a model that uses an approach that works with all four components.

What Is Recovery?

A comprehensive model of chemical dependency treatment effectively combines the best of the medical and social/behavioral treatment models. It is based on the idea that recovery is a process that takes place over time, in specific stages. Each stage has tasks to be accomplished and skills to be developed. If a recovering person is unaware of this progression, unable to accomplish the tasks and gain the skills, or lacks adequate treatment, he or she will relapse.

The Developmental Model of Recovery

The DMR has been devised to help recovering people and treatment professionals identify appropriate recovery plans, set treatment goals, and measure progress. The DMR describes six stages or periods of recovery.

Transition Stage

The transition stage begins the first time a person experiences an alcohol or drug‑related problem. As a person's addiction progresses, he or she tries a series of strategies designed to control use. This ends with recognition by the person that safe use of alcohol and/or drugs is no longer possible.

The struggle for control is a symptom of a fundamental conflict over personal identity. Alcoholics and drug addicts enter this phase of recovery believing they are normal drinkers and drug users capable of controlled use. As the progression of addiction causes more severe loss of control, they must face the fact that they are addictive users who are not capable of controlled use.

During the transition stage, chemically dependent people typically attempt to control their use or stop using. They are usually trying to prove to themselves and others that they can use safely. This never works for very long. Controlled use is especially tough for people who are participating in criminal behavior because the high level of alcohol and drug use among their peers makes their lifestyle and use seem normal. The major cause of inability to abstain during the transition stage is the belief that there is a way to control use.

Stabilization Period

During the stabilization period, chemically dependent people experience physical withdrawal and other medical problems, learn how to break the psychological conditioning causing the urge to use, stabilize the crisis that motivated them to seek treatment, and learn to identify and manage symptoms of brain dysfunction. This prepares them for the long‑term processes of rehabilitation.

Traditional treatment often underestimates the need for management of these issues, focusing instead on detoxification. Patients find themselves unable to cope with the stress and pressure of the symptoms of brain dysfunction and physical cravings that follow detoxification. Many have difficulty gaining much from treatment and feel they are incapable of recovery. The lack of a supportive environment for recovery that many criminal offenders experience adds stress and undermines their attempts to stabilize these symptoms. They often use alcohol and drugs to relieve such distress. It takes between 6 weeks and 6 months for a patient to learn to master these symptoms with the correct therapy. The major cause of inability to abstain during the stabilization period is the lack of stabilization management skills.

Early Recovery Period

Early recovery is marked by the need to establish a chemical‑free lifestyle. The recovering person must learn about the addiction and recovery process. He or she must separate from friends who use and build relationships that support long‑term recovery. This may be a very difficult time for criminal justice patients who have never associated with people with sobriety‑based lifestyles.

They also need to learn how to develop recovery‑based values, thinking, feelings, and behaviors to replace the ones formed in addiction. The thoughts, feelings, and behaviors developed by people with criminal lifestyles complicate and hinder their involvement in appropriate support programs during this period. Major intervention to teach the patient these skills is necessary if he or she is to succeed. This period lasts about 1 to 2 years. The primary cause of relapse during the early recovery period is the lack of effective social and recovery skills necessary to build a sobriety‑based lifestyle.

Middle Recovery Period

Middle recovery is marked by the development of a balanced lifestyle. During this stage, recovering people learn to repair past damage done to their lives. The recovery program is modified to allow time to reestablish relationships with family, set new vocational goals, and expand social outlets. The patient moves out of the protected environment of a recovery support group to assume a more mainstream and normal lifestyle. This is a time of stress as a person begins applying basic recovery skills to real‑life problems. The major cause of relapse during the middle recovery period is the stress of real‑life problems.

Late recovery period

During late recovery, a person makes changes in ongoing personality issues that have continued to interfere with life satisfaction. In traditional psychotherapy, this is referred to as self‑actualization. It is a process of examining the values and goals that one has adopted from family, peers, and culture. Conscious choices are then made about keeping these values or discarding them and forming new ones. In normal growth and development, this process occurs in a person's mid‑twenties. Among people in recovery, it does not usually occur until 3 to 5 years into the recovery process, no matter when recovery begins.

For criminal offenders, this is the time when they learn to change self‑defeating behaviors that may trigger a return to alcohol or drug use. These self‑defeating behaviors often come from psychological issues starting in childhood, such as childhood physical or sexual abuse, abandonment, or cultural barriers to personal growth. The major cause of relapse during the late recovery period is either the inability to cope with the stress of unresolved childhood issues or an evasion of the need to develop a functional personality style.

Maintenance Stage

The maintenance stage is the life‑long process of continued growth and development, coping with adult life transitions, managing routine life problems, and guarding against relapse. The physiology of addiction lasts for the rest of a person's life. Any use of alcohol or drugs will reactivate physiological, psychological, and social progression of the disease. The major causes of relapse during the maintenance stage are the failure to maintain a recovery program and encountering major life transitions.

Stuck Points in Recovery

Although some patients progress through the stages of recovery without complications, most chemically dependent people do not. They typically get stuck somewhere. A “stuck point" can occur during any period of recovery. Usually it is caused either by lack of skills or lack of confidence in one's ability to complete a recovery task. Other problems occur when the recovering person encounters a problem (physical, psychological, or social) that interferes with his or her ability to use recovery supports.

When recovering people encounter stuck points, they either recognize they have a problem and take action, or they lapse into the familiar coping skill of denial that a problem exists. Without specific relapse prevention skills to identify and interrupt denial, stress begins to build. Eventually, the stress will cause the patient to cope less and less well. This will result in relapse.

The Developmental Model of Recovery Compared With Traditional Models

Traditional models of treatment are based on the idea that once a person is detoxified, he or she can fully participate in the treatment process. Although this is true for many patients in the early stages of addiction who have had functional lives before their addiction progressed, it is not true for most of the criminal justice population. In addition, most traditional programs have a program format that is applied to all people regardless of their education, personality, or social skills. Patients whose needs fit within the program usually do well. But those, whose needs do not fit, such as criminal justice patients, generally do not do well.

The DMR recognizes that there are abstinence‑based symptoms of addiction that persist well into the recovery process. These symptoms are physical and psychological effects of the disease of chemical dependency. In the DMR, these symptoms must be stabilized and the patient must be taught how to manage them before general rehabilitation can take place. This model identifies the specific symptoms that a patient needs to overcome.

This model also contains methods and techniques that recognize the learning needs, psychological problems, and social skills of the patient.

Post Acute Withdrawal

Some of the symptoms of withdrawal from alcohol or drugs are the result of the toxic effects of these chemicals on the brain. These symptoms are called Post Acute Withdrawal (PAW). PAW is more severe for some patients than it is for others. Other factors cause stress that aggravates PAW. Below is a list of conditions affecting the criminal justice population that tends to worsen the damage and aggravate PAW.

Physical conditions that worsen PAW through increased brain damage or disrupted brain function:

• Combined use of alcohol and drugs or different types of drugs

• Regular use of alcohol or drugs before age 15 or abusive use for a period of more than 15 years

• History of head trauma (from car accidents, fights, falling, etc.)

• Parental use of alcohol or drugs during pregnancy

• Personal or family history of metabolic disease such as diabetes or hypoglycemia

• Personal history of malnutrition, usually due to chemical dependence

• Physical illness or chronic pain.

Psychological and social conditions that worsen PAW:

• Childhood or adult history of psychological trauma (participant in or victim of sexual or physical violence)

• Mental illness or severe personality disorder

• High stress lifestyle or personality

• High stress social environment.

Addictive Preoccupation

The other major area of abstinence‑based symptoms is addictive preoccupation. This consists of the obsessive thought patterns, compulsive behaviors, and physical cravings caused or aggravated by the addiction. These behaviors become programmed into the patient's psychological processes by the addiction. They are automatic and can cause the recovering patient to return to use unless he or she has specific training to identify and interrupt them.

Addictive preoccupations are activated by high‑risk situations and stress. Because of the environment surrounding most criminal justice patients, they often experience high‑risk situations and stress. These situations and stresses can include:

• Exposure to alcohol or drugs or associated paraphernalia

• Exposure to places where alcohol or drugs are used

• Exposure to people with whom the patient has used in the past or people the patient knows who are actively using

• Lack of a stable home environment

• Lack of a stable social environment

• Lack of stable employment.

Traditional treatment focuses on either detoxification alone or detoxification with movement into a rehabilitation program aimed at changing the patient's lifestyle. Programs are similar for all patients. Many programs omit teaching the specific stabilization skills that are necessary before lifestyle rehabilitation can take place.

The DMR first stabilizes patients so that they can take advantage of lifestyle rehabilitation. It then places the patient into a group that contains patients in similar stages of recovery and works on tasks and skills for that stage of recovery. Specific skills are taught to identify and manage relapse warning signs.

What Is Relapse?

Relapse is not an isolated event. Rather, it is a process of becoming unable to cope with life in sobriety. The process may lead to renewed alcohol or drug use, physical or emotional collapse, or suicide. The relapse process is marked by predictable and identifiable warning signs that begin long before a return to use or collapse occurs. Relapse prevention therapy teaches people to recognize and manage these warning signs so that they can interrupt the progression early and return to the process of recovery.

Studies of life‑long patterns of recovery and relapse indicate that not all patients relapse. Approximately one third achieve permanent abstinence from their first serious attempt at recovery. Another third have a period of brief relapse episodes but eventually achieve long‑term abstinence. An additional one third have chronic relapses that result in eventual death from chemical addiction.

These statistics are consistent with the life‑long recovery rates of any chronic lifestyle‑related illness. About half of all relapse‑prone people eventually achieve permanent abstinence. Many others lead healthier, more stable lives despite periodic relapse episodes.

Classification of Recovery/Relapse History

For the purpose of relapse prevention therapy, chemically dependent people can be categorized according to their recovery/relapse history. These categories are as follows:

• Recovery‑Prone

• Briefly Relapse‑Prone

• Chronically Relapse‑Prone.

These categories correspond with the outcome categories of continuous abstinence, brief relapse, and chronic relapse described above. Relapse‑prone individuals can be further divided into three distinct subgroups.

Transition patients fail to recognize or accept that they are suffering from chemical addiction in spite of problems from their use. This failure is usually due to the chemical disruption of the patient's ability to accurately perceive reality, or to mistaken beliefs.

Un-stabilized relapse‑prone patients have not been taught to identify the abstinence‑based symptoms of PAW and addictive preoccupation. Treatment fails to provide these patients with the skills necessary to interrupt their disease progression and stop using alcohol and drugs. As a result, they are unable to adhere to a recovery program requiring abstinence, treatment, and lifestyle change.

Stabilized relapse‑prone patients recognize that they are chemically dependent, need to maintain abstinence to recover, and need to maintain an ongoing recovery program to stay abstinent. They usually attend Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or another 12‑step program in addition to receiving ongoing professional treatment. They also make protracted efforts at psychological and physical rehabilitation and recommended lifestyle changes during abstinence. However, despite their efforts, these people develop symptoms of dysfunction that eventually lead them back to alcohol or drug use.

Many counselors mistakenly believe that most relapse‑prone patients are not motivated to recover. Clinical experience has not supported this belief. More than 80 percent of relapse‑prone patients admitted to the relapse prevention program at Father Martin's Ashley in Havre de Grace, Maryland, had a history of both recognition of their chemical addiction and motivation to follow aftercare recommendations at time of discharge. In spite of this, they were unable to maintain abstinence and sought treatment in a specialized relapse prevention program. He or she became aware of during this exercise.

What Is Relapse Prevention Treatment?

Relapse prevention is a systematic method of teaching recovering patients to recognize and manage relapse warning signs. Relapse prevention becomes the primary focus for patients who are unable to maintain abstinence from alcohol or drugs despite primary treatment.

Recovery is defined as abstinence plus a full return to bio/psycho/social functioning. As previously noted, relapse is defined as the process of becoming dysfunctional in recovery, which leads to a return to chemical use, physical or emotional collapse, or suicide. Relapse episodes are usually preceded by a series of observable warning signs. Typically, relapse progresses from bio/psycho/social stability through a period of progressively increasing distress that leads to physical or emotional collapse. The symptoms intensify unless the individual turns to the use of alcohol or drugs for relief.

To understand the progression of warning signs, it is important to look at the dynamic interaction between the recovery and relapse processes. Recovery and relapse can be described as related processes that unfold in six stages:

• Abstaining from alcohol and other drugs

• Separating from people, places, and things that promote the use of alcohol or drugs, and establishing a social network that supports recovery

• Stopping self‑defeating behaviors that prevent awareness of painful feelings and irrational thoughts

• Learning how to manage feelings and emotions responsibly without resorting to compulsive behavior or the use of alcohol or drugs

• Learning to change addictive thinking patterns that create painful feelings and self‑defeating behaviors

• Identifying and changing the mistaken core beliefs about oneself, others, and the world that promotes irrational thinking.

When people who have had a stable recovery and have done well begin to relapse, they simply reverse this process. In other words, they:

• Have a mistaken belief that causes irrational thoughts

• Begin to return to addictive thinking patterns that cause painful feelings

• Engage in compulsive, self‑defeating behaviors as a way to avoid the feelings

• Seek out situations involving people who use alcohol and drugs

• Find themselves in more pain, thinking less rationally, and behaving less responsibly

• Find themselves in a situation in which drug or alcohol use seems like a logical escape from their pain, and they use alcohol or drugs.

A number of basic principles and procedures underlie the CENAPS Model of Relapse Prevention Therapy. Each principle forms the basis of specific relapse prevention therapy procedures. Counselors can use the following principles and procedures to develop appropriate treatment plans for relapse‑prone patients. Following a description of each principle is the relapse prevention procedure for that principle.

Principle 1: Self‑Regulation

The risk of relapse will decrease as a patient's capacity to self‑regulate thinking, feeling, memory, judgment, and behavior increases.

Relapse Prevention Procedure 1: Stabilization: An initial treatment plan is established that allows relapse‑prone individuals to stabilize physically, psychologically, and socially. The level of stabilization is measured by the ability to perform the basic activities of daily living. Because the symptoms of withdrawal are stress‑sensitive, it is important to evaluate the patient's level of stability under both high and low stress. Many people who appear stable in a low‑stress environment become unstable when placed in a more stressful environment.

The stabilization process often includes:

• Detoxification from alcohol and other drugs

• Solving the immediate crises that threaten sobriety

• Learning skills to identify and manage Post Acute Withdrawal and Addictive Preoccupation

• Establishing a daily structure that includes proper diet, exercise, stress management, and regular contact with treatment personnel and self‑help groups.

Because the risk of using alcohol or drugs is highest during the stabilization period, steps must be taken to prevent use during this time. The patient needs to be in a drug‑free environment. Any irrational thoughts (thoughts that don't make sense to a healthy person) that are creating immediate justification for relapse need to be identified and discussed. The patient should then be helped to remember the consequences of past chemical use and to develop new coping strategies.

An early relapse intervention plan can be developed by the counselor and patient to decide what action to take if the patient begins to use alcohol or drugs. This early intervention plan motivates the patient to stay sober and provides a safety net should chemical use occur.

Principle 2: Integration

The risk of relapse will decrease as the level of conscious understanding and acceptance of situations and events that have led to past relapses increases.

Relapse Prevention Procedure 2: Self‑Assessment: Self‑assessment first involves a detailed reconstruction of the presenting problems (problems that caused the patient to seek treatment) and the alcohol and drug use history. A careful exploration of the presenting problems identifies critical issues that can trigger relapse. This allows the counselor to design intervention plans that help to solve crises that can be used for relapse justification in the early treatment stages. The next step is a reconstruction of the recovery and relapse history. This helps identify past causes of relapse.

In reconstructing the recovery/relapse history, it is important to identify the recovery tasks that were completed or ignored, and to find the sequence of warning signs that led back to drug or alcohol use. The assessment is most effective if the counselor reconstructs the relapse history using exercises (done as homework assignments), such as making a list of all relapse episodes and identifying the problems that led to relapse. These assignments should be reviewed in group and individual sessions.

Principle 3: Understanding

The risk of relapse will decrease as the understanding of the general factors that cause relapse increases.

Relapse Prevention Procedure 3: Relapse Education: Relapsers need accurate information about what causes relapse and what can be done to prevent it. This is typically provided in structured relapse education sessions and reading assignments, which provide specific information about recovery, relapse, and relapse prevention planning methods. This information should include, but not be limited to:

• A bio/psycho/social model of addictive disease

• A DMR

• Common stuck points" in recovery

• Complicating factors in relapse

• Warning sign identification

• Relapse warning sign management strategies

• Effective recovery planning.

The recommended format for a relapse education session is as follows:

• Introduction and pretest (15 minutes)

• Educational presentation/lecture, film, or videotape (30 minutes)

• Educational exercise conducted in dyads or small groups (15 minutes)

• Large group discussion (15 minutes)

• Post‑test session and review of correct answers (15 minutes).

It is important to test patients to determine their retention and understanding of the material. Many relapsers have severe memory problems associated with Post Acute Withdrawal that prevent them from comprehending or remembering educational information.

Principle 4: Self‑Knowledge

The risk of relapse will decrease as the patient's ability to recognize personal relapse warning signs increases.

Relapse Prevention Procedure 4: Warning Sign Identification: Warning sign identification is the process of teaching patients to identify the sequence of problems that has led from stable recovery to alcohol and drug use in the past and then recognizing how those steps could cause relapse in the future. The process of developing a personal relapse warning sign list is (1) reviewing warning signs, (2) making an initial warning sign list, (3) analyzing warning signs, and (4) making a final warning sign list.

The patient develops his or her own individualized warning sign list by thinking of irrational thoughts, unmanageable feelings, and self‑defeating behaviors. Most final warning sign lists identify two different types of warning signs: those related to core psychological issues (problems from childhood) and those related to core addictive issues (problems from the addiction). Warning signs related to core psychological issues create pain and dysfunction, but they do not directly cause a person to relapse into chemical use. When patterns of addictive thinking that justify relapse are reactivated, a return to using alcohol and drugs occurs.

Principle 5: Coping Skills

The risk of relapse will decrease as the ability to manage relapse warning signs increases.

Relapse Prevention Procedure 5: Warning Sign Management: This involves teaching relapse‑prone patients how to manage or cope with their warning signs as they occur. The better they are at coping with warning signs, the better their ability will be to stay in recovery. Warning sign management should focus on three distinct levels. The first is the situational‑behavioral level, where patients are taught to avoid situations that trigger warning signs. At this level, they are taught to modify their behavioral responses should these situations arise. The second level is the cognitive affective (thoughts and feelings) level, where patients are taught to challenge their irrational thoughts and deal with their unmanageable feelings that emerge when a warning sign is activated. The third level is the core issue level, where patients are taught to identify the core addictive and psychological issues that initially create the warning signs.

Principle 6: Change: The risk of relapse will decrease as the relationship between relapse warning signs and recovery program recommendations increases.

Relapse Prevention Procedure 6: Recovery Planning: Recovery planning involves the development of a schedule of recovery activities that will help patients recognize and manage warning signs as they develop in sobriety. This is done by reviewing each warning sign on the final warning sign list and ensuring that there is a scheduled recovery activity focused on each sign. Each critical warning sign needs to be linked to a specific recovery activity.

Principle 7: Awareness: The risk of relapse will decrease as the use of daily inventory techniques designed to identify relapse warning signs increases.

Relapse Prevention Procedure 7: Inventory Training: Inventory training involves teaching relapse‑prone patients to complete daily inventories. These inventories monitor compliance with the recovery program and check for the emergence of relapse warning signs. A daily recovery plan sheet is used to plan the day, and an evening inventory sheet is used to review progress and problems that occurred during that day.

A typical morning inventory asks the patient to identify three primary goals for that day, create a to‑do list, and then schedule time for completion of each task on the to‑do list on a daily calendar. During the evening review inventory, the patient should review his or her warning sign list and recovery plan to determine whether he or she completed the required activities and experienced any relapse warning signs.

Whenever possible, these inventories should be reviewed by someone who knows the patient and who can assist him or her in looking for emerging patterns of problems that could cause relapse.

Principle 8: Significant Others: The risk of relapse will decrease as the responsible involvement of significant others in recovery and in relapse prevention planning increases.

Relapse Prevention Procedure 8: Involvement of Others: Relapse‑prone individuals cannot recover alone. They need the help of others. Family members, 12‑step program sponsors, counselors, and peers are just a few of the many recovery resources available. A counselor should ensure that others are involved in the recovery process whenever possible. The more psychologically and emotionally healthy the significant others are, the more likely they are to help the relapse‑prone patient remain abstinent. The more directly the significant others are involved in the relapse prevention planning process, the more likely they are to become productively involved in supporting positive efforts at

recovery and intervening on relapse warning signs or initial chemical use.

Principle 9: Maintenance: The risk of relapse decreases if the relapse prevention plan is regularly updated during the first 3 years of sobriety.

Relapse Prevention Procedure 9: Relapse Prevention Plan Updating: The patient's relapse prevention plan needs to be updated on a monthly basis for the first 3 months, quarterly for the remainder of the first year, and twice a year for the next 2 years. Once a person has maintained 3 years of uninterrupted sobriety, the relapse prevention plan should be updated on a yearly basis.

Nearly two thirds of all relapses occur during the first 6 months of recovery. Less than one quarter of the variables that actually cause relapse can be predicted during the initial treatment phase. As a result, ongoing outpatient treatment is necessary for effective relapse prevention. Even the most effective short‑term inpatient or primary outpatient programs will fail to interrupt long‑term relapse cycles without the ongoing reinforcement of some type of outpatient therapy.

A relapse prevention plan update session involves the following:

• A review of the original assessment, warning sign list, management strategies, and recovery plan.

• An update of the assessment by adding documents that are significant to progress or problems since the previous update.

• A revision of the relapse warning sign list to incorporate new warning signs that have developed since the previous update.

• The development of management strategies for the newly identified warning signs.

• A revision of the recovery program to add recovery activities to address the new warning signs and to eliminate activities that are no longer needed.

Basic Counseling Skills

Although the workbook is intended to be used in a group counseling session, occasionally you will need to do individual counseling. This chapter discusses some basic counseling skills that can be used in individual and group counseling. It also explains some of the concepts and terms used in relapse prevention counseling that you will need to help patients with the workbook.

Helping Traits

People who are effective at counseling have developed eight behaviors that they use during counseling sessions. It is important to develop these traits if you are to improve your ability to help others. The counselor is a role model (someone whom patients tend to imitate). Therefore, you want to model behaviors that will be helpful to patients' recovery. The following are some of these traits.

Empathy. Empathy is the ability to understand how another person sees and interprets an experience. It is different from sympathy (feeling sorry for someone). When you are empathetic, you can look at and understand a situation from another person's perspective. It does not mean you have to agree with that person.

Genuineness. Genuineness is the ability to be fully yourself and express yourself to others. It is the lack of phoniness, faking, and defensiveness. When you are genuine, the way you act on the outside matches your thoughts and feelings on the inside.

Respect. Respect is the ability to let another person know, through your words and actions, that you believe that he or she has the ability to make it in life, the right to make his or her own decisions, and the ability to learn from the outcome of those decisions.

Self‑Disclosure. Self‑disclosure is the ability to disclose information about yourself the ways you think and feel, the things you believe in order to help other people.

Warmth. Warmth is the ability to show another person you care about him or her. Behaviors that show warmth include touching someone, making eye contact, smiling, and having a caring, sincere tone of voice.

Immediacy. Immediacy is the ability to focus on the "here and now" relationship with another person. You can express immediacy by saying things like: "Right now I am feeling ________." "When you said that, I began to think _________." "As you were speaking, I sensed that you felt __________."

Concreteness. Concreteness is the ability to identify specific problems and the steps necessary to correct them. When a problem, situation, behavior, or set of actions is defined in concrete terms, you could draw a picture or make a movie about it if you were able.

Confrontation. Confrontation is the act of honestly telling another person your perception of what is going on without putting them down. Confronting someone can include:

• Giving an honest evaluation of the person's strengths and weaknesses

• Saying what you believe the person is thinking and feeling

• Stating how you see the person acting

• Telling the person what you believe will happen because of their actions.

Active Listening. When a patient is talking about a problem or presenting an assignment, it is important to listen actively. Active listening is a basic counseling skill that helps you clarify for yourself and the patient what is really going on. Patients in recovery are not always clear in their thinking. This lack of clarity can confuse them and those around them. Active listening will help them clarify their thinking.

Active thinking consists of several skills. These include the following: Clear listening. When you are listening to a patient, it is important to just listen. The most common problem for new counselors

is that they think while they listen. If you are thinking about what you are going to say, you will not accurately hear what the person is saying. It is important that you listen without judging what the patient is saying and without immediately trying to correct

his or her thoughts.

Reflecting. When someone talks to you, reflecting is summarizing and repeating that person's thoughts and feelings in a simple, clear manner. Reflecting helps clarify the issues for both of you. If you misunderstand the patient, he or she can correct you. When you repeat thoughts and feelings back to the patient, use statements instead of questions. Example: Patient—"I try and try to stay straight but everything goes wrong and I end up using again." Counselor‑"You seem to feel hopeless about recovering." Reflecting gives a patient the sense that you are really listening. He or she will tend to open up more and talk about problems he or she hasn't talked about before.

Asking‑open ended questions. Do not ask questions that can be answered with a "yes" or a "no." Instead, ask questions that require patients to explore the reasons they think, feel, and act the way they do. Example: "What happens when you try to recover?" "What do you do when you feel hopeless?" Not asking "Why?” Most new counselors make the mistake of asking "Why?" The patient does not know why, or else he or she would have changed. If you ask "Why?" the patient will give you an excuse. By asking "What?" you are getting the patient to focus on what he or she has done that can be changed.

Using effective body language. How you physically position yourself tells a patient a lot about how you feel about him or her. When you are working with patients, it is best to sit with your legs and arms uncrossed, to lean forward and to make eye contact. This body position shows that you are interested in what the patient has to say and that you are paying attention.

Watching for nonverbal cues. When you are working with a patient, listen and watch carefully. Does the person tense up; tap his or her foot, shift around, etc.? When you see these cues, make the patient aware of them and let him or her know what this might mean the patient is feeling.

Basic Relapse Prevention Techniques

There are a number of techniques that are used when doing relapse prevention counseling.

Centering: When you begin a group or an individual session or when you want a patient to calm down and get in touch with thoughts and feelings, you can use a technique called centering. This is basically a relaxation technique. Instruct the patient to do the following:

• Put both feet on the floor, sit up straight and close your eyes.

• Breathe in through your nose and out through your mouth.

• Breathe in deeply, hold it for a second, and then breathe out.

• Do this again and feel your lungs fill with air, then empty.

• Slow your breathing to a steady rhythm.

• See if any thoughts are entering your mind.

• Ask yourself if you are feeling anybody tensions.

• Open your eyes when you are ready.

Speak slowly as you give the instructions. This will help the patient calm down.

Sentence completion: Sentence completion is a technique used to help patients identify thoughts that they have that may not be true. These thoughts are called mistaken beliefs. Many times when a patient is acting in a self‑defeating way, it is a result of mistaken beliefs he or she has about the world and himself or herself. When a patient is behaving in a way that hurts himself or herself and others, it is because the patient believes that this is the only choice he or she has. Sentence completion is a way to help a patient identify and correct mistaken beliefs. You do this by doing the following: Have the patient form a sentence stem: A sentence stem is the beginning of a sentence that has meaning for the patient. You can form these stems based on topics the patient is talking about. Examples are: "I know my recovery is in trouble when . . ." "When I think about drugs, I . . ." "Right now, I am feeling . . ." Have the patient write down the sentence stem. Have the patient repeat it out loud and end it differently six to eight times or until he or she cannot think of new endings. Have the other group members write down the endings. If you are in an individual session, do this yourself. Have the group members read the endings back to the patient as they write them down. Have them use the following form: a (patient's name), I heard you say (sentence stem) (first ending)." Repeat the exercise until all the endings have been read. Look for a common theme in the endings. You may form a new sentence stem from the common theme and repeat the exercise, or stop here if the mistaken belief is identified. Have the patient identify the mistaken belief if he or she can and write it down.

Sentence repetition: Sentence repetition is a way for a patient to become conscious of mistaken beliefs and the thoughts, feelings, and actions they cause. Identify the mistaken belief and ask the patient to write it down. Ask the patient to repeat it out loud, slowly. After each repetition, ask the patient to take a deep breath, let it out, and report any thoughts, feelings, or urges that surfaced. Have the patient write down these thoughts, feelings, and urges. Ask the patient if he or she can remember who caused this mistaken belief or where it came from. Ask the patient if the person could have been wrong. Ask the patient if there are other ways to believe that could be true. You may have to ask the group to help. Ask the patient to complete the following sentences:

• "If I continue to believe this, the best that can happen is . . ."

• "The worst that can happen is . . ."

• "The most likely to happen is . . ."

• "If I change what I believe, the best that can happen is . . ."

• "The worst that can happen is . . ."

• "The most likely to happen is . . ."

The probable outcomes can be discussed and a course of action decided by the group. The most important decision is to identify a rational thought that the patient can substitute when the mistaken belief occurs.

Group Counseling

Group counseling has proved to be the most effective way of treating chemical dependency. This chapter explains how to do group counseling. Patients in chemical dependency treatment programs learn best in group counseling, where patients learn about themselves by interacting with others. They also come to understand that they are not alone in their problems. In addition, they learn social and communication skills that allow them to make better use of self‑help programs such as Alcoholics Anonymous and Narcotics Anonymous.

How Is Group Work Different From Individual Counseling?

Group counseling and individual counseling are both important tools for treating chemical dependency. Group counseling uses many of the same intervention strategies as individual counseling. There are, however, some important distinctions between the two modalities. A common mistake for beginning group counselors is to focus an entire group meeting on one patient, while the

others in the group simply look on.

Group counseling is different from individual counseling in the following ways:

• Group counseling focuses on the present; the here and now. In group counseling, patients do not delve into long accounts of personal history that preceded the problems of chemical dependency. Group counseling provides a forum to understand current behavior, to learn about chemical dependency, to discuss new ways of behaving, to learn new ways to solve problems, and to develop relapse prevention skills.

• Group counseling makes use of the interactive process within the group. That is, the counselor focuses on how the group members act toward one another, communicate with one another, and how they behave in the group.

• The counselor and group members offer individuals feedback about their behavior. In individual counseling patients simply disagree with their counselor. In group counseling the counselor's feedback is combined with positive peer feedback from the group members. This makes messages more powerful.

• The group provides a place for the counselor to help individuals practice new skills such as problem solving, communication, and managing stress.

In group counseling, the counselor uses a peer group to influence individual patients and change behavior in a positive way.

Group Counseling Theory

Stages of Group Development: When a group first begins, counselors and group members alike will feel very uncomfortable. The members may not know the counselor or one another. As people become familiar with the group, feelings and behavior begin to change. These changes follow predictable patterns. In fact, groups have a clear developmental life cycle, that is, a group goes through different stages. As the group leader gains experience, he or she learns to anticipate these changes and work with them.

There are many models for the stages of group development. The following is a composite of several models:

Stage 1—Pre-affiliation

Stage 2—Power and control

Stage 3—Intimacy

Stage 4—Differentiation

Stage 5—Separation.

In the pre-affiliation stage, members feel uncomfortable, anxious, or fearful with the newness of the experience. In this stage, members look to the leader for direction. Initially, the group should be leader focused, with the leader helping members adjust to the new experience.

Once group members are more comfortable, it is predictable that they will challenge the authority of the leader and will pursue power and control. It is important for the leader to remember that this is a normal style in the group's development, not unlike the challenges that face the parents of an adolescent. This phase may be uncomfortable, with group members expressing anger and frustration. The leader should be careful not to personalize these challenges to authority. The leader should be consistent, avoid fighting with the group, and allow the group to become more autonomous without sacrificing his or her position of authority.

In the next stage, some degree of intimacy is established. It is very important for the leader to move members to a common level of intimacy before allowing too much self-disclosure by the group members. The setting and type of the group will determine the overall level of intimacy. As members feel safer in the group, they can better engage in activities and take risks necessary for change. At this stage, the leader can give less direction, allowing the members to work together more spontaneously and more independently.

Differentiation is the stage at which members have a strong sense of identification with the group and feel trusting. This is the most productive stage of group development.

Finally, at the point of termination or separation, members experience a range of feelings and display a range of behaviors in anticipation of leaving the group. It is important to remember that chemically dependent people typically have experienced a lot of loss over their lifetimes. Many have lost family members and friends to violence and illness. They do not handle the ending of relationships well. Termination of the group or loss of a group member presents an important opportunity to deal with this problem. The leader should begin to prepare the group for ending well in advance and do so gradually. The leader can expect members to use denial or to regress. It is important to predict these behaviors and to identify them as they occur.

These stages of group development are very predictable. Virtually all groups go through them. However, depending upon the circumstances a group may regress to an earlier stage at any time. For example, if a group adds new members, the level of intimacy will decrease. The group may return to a stage of pre-affiliation. It is hard to predict how long a group will stay in a particular stage of development. The type of group (i.e., mandatory or voluntary), the setting (i.e. institution or community), and other factors can all influence the process. With experience, the group leader develops the skills to promote the group developmental process or alter.

Communication in Groups: Content and Interactive Process: The terms "content" and "interactive process" refer to the patterns of communication among group members. "Content" refers to the substance of a communication. The content is the subject matter, including issues, questions, or problems on which the group is focused. "Interactive process" refers to how members communicate and act with one another. The process includes not only the spoken words, but also the nonverbal messages expressed by tone of voice, posture, and facial expression. Process provides the "present focus" or "here and now" raw material for group treatment.

The content of a group meeting sometimes symbolizes the group process. In the same way a client might talk about "a friend who has a problem," group members may talk about prior events and issues that reflect current experiences. Often as group leaders, we get caught up in the content. We are very interested in the what, when, where, who, how, and why. In group counseling, this content has relevance in a way that can be different from its relevance in individual counseling.

The Counselor as Group Leader: Many techniques used in group counseling are similar to those used in individual counseling. The general approach of the group leader, however, must work to create a group culture that focuses on the “here and now" behavior. An active and dynamic approach along with an empathic style is needed to do this. The group leader's focus should:

• encourage group and individual recovery

• teach members about chemical dependency, recovery, and relapse prevention

• build members' self‑esteem.

The group leader's approach should:

• be empathic

• instill hope

• model desired behaviors

• treat all members consistently, equally, and fairly

• be active and directive

• use appropriate interventions to keep the group moving.

The group leader should:

• maintain control in a non-authoritative way

• be firm but not punitive

• be assertive in setting limits

• provide appropriate rewards (activities, trips, etc.) to the group.

Planning for Group Work

Logistics: All logistical arrangements should be planned well in advance of beginning the group. In order for the preplanning to go smoothly, group counselors should seek the support of appropriate administrative and support staff. Establish the following before getting started.

Group Size: Groups typically range in size from 6 to 12 people. The size should be determined by such factors as the type of group and the capacity of the patients. "Capacity" refers to the level of individual functioning. Can the patient concentrate, focus, and pay attention? Some substance abusers, particularly those in the early stages of recovery, cannot make use of all their mental functions. Others may have mental/emotional problems that interfere with these abilities. Low functioning individuals will need a smaller group. Educational groups can handle more members, whereas process oriented groups should be smaller.

Time: Time is an important boundary. The length of group sessions should be preplanned if the group is to be time limited. A schedule of sessions should be established that considers holidays and other commitments. Sessions should be of equal length. The ideal length depends on the capacity of the patients, the setting, and the type of group. More functional patients can handle longer sessions than less functional or younger patients. The materials presented in this manual are intended for two‑hour group sessions. Once the time boundaries have been established, it is very important to begin and end group sessions on time.

Space: The space chosen for group meetings will make a statement about the importance given to this activity. The space should be psychologically positive and provide a safe environment for the emotional risks that go with treatment. The space should be well lighted, well ventilated, and an appropriate size for the size of the group. A private location that is accessible, free from interruptions, and physically safe should be chosen.

Types of Groups: Different types of groups serve different purposes. The following is a review of some options to help you decide what type of group is most practical and useful for the setting.

Mandatory or Voluntary Group? You might assume that voluntary groups are best, but research and practice indicate that both voluntary and mandatory groups have their advantages and disadvantages.

Mandatory groups ensure that members will attend. With regular attendance the group process can develop with little disruption. Unfortunately, mandatory requirements often increase hostility and resistance and intensify denial. No one likes to be told they must go to a counseling group, and few counselors like being confronted with such hostility, particularly by a group of eight or more people.

When the counselor is well prepared, the situation can be managed. Patients will attempt to engage you in battle. The best tactic is to avoid these battles. One way to do so is to join with the group by saying something like, "You have to be here and I have to be here. I understand and appreciate your anger but it is not my fault. How can we both make the best of things?" Offering concrete rewards for cooperation may also help. Setting rules for attendance can eliminate overt resistance but seldom reduces passive resistance.

The disadvantages of the mandatory group become the advantages of the voluntary group. Members of voluntary groups identify with one another, denial is less potent, there is less hostility, and one can move on more quickly to group goals. However, the voluntary group does not have some major disadvantages. When participation is voluntary, members often find excuses to be absent when there is pressure on them to face problems. Without a "captive" audience, leaders find that it is hard to ensure member attendance and that it is difficult for the group process to evolve with absent members.

Which type of group is best? Research indicates that mandatory treatment works as well as voluntary treatment with substance abusers. In a criminal justice setting, required attendance can be useful for all.

Open or Closed Group Membership? One issue to be decided in advance is whether or not to add members after the group has started. The terms “open membership" and "closed membership" are used to describe the two options. Open membership can reach more clients and is easier to keep going over time because lost members can be replaced. However, adding new members can cause a loss of group intimacy and cohesiveness. Development may regress. Although this may not be ideal, depending on the goals of group, adaptations can be made. Closed membership allows for greater individual progress but is impractical in some settings.

Time‑Limited or Open‑Ended Group? It may be practical to place a time limit on a group depending on the patients' stage of recovery. This way patients graduate together to another group with another specified goal. If the setting allows, an open‑ended, closed membership group can be ideal. Such a group can achieve high levels of intimacy and differentiation that allow for greater risk taking. The goals can advance while the membership remains the same.

Educational Groups? For patients to succeed in recovery, they must learn certain things about chemical dependency. This information helps them to cope with the challenges of recovery and avoid relapse. Educational groups also help engage the client in treatment and recovery. The overt or covert expectation of individual or group therapy is "change." People find this threatening. An educational group is much less threatening because it is easier to “learn" than to “change." Educational sessions can be offered in 60‑ to 90‑minute blocks. The educational sessions should offer basic information on:

• Chemical dependency as a bio/psycho/social disease

• The recovery process

• Symptoms that appear after beginning abstinence

• Relapse warning signs

• Recovery planning.

Group Goals and Principles

It is important for the group leader to be clear about what is to be accomplished in the group. It is best to have a written goal with a step‑by‑step plan for reaching the goal. Having both a written goal and a plan will help to keep the group on track.

The goals of group treatment with addicted patients should be: Self‑assessment. The patients should be able to talk about and understand the meaning of different exercises to their recovery.

Communication training. The group leader should teach patients basic techniques for talking about their thoughts, feelings, and reports of life events. This training should focus on teaching patients how to reveal things about themselves and how to give and receive feedback.

Cognitive restructuring. Patients should relearn how to think so that they can accurately examine and report information and understand how it pertains to their recovery.

Effective counseling. Group treatment should teach patients how to identify, express and self‑regulate their emotions and moods.

Memory retraining. Treatment should help patients restore short‑term and long‑term memory.

Treatment monitoring. Group sessions should provide a vehicle for monitoring and holding the patient accountable for progress and problems encountered when pursuing treatment goals.

Support. The group leader should provide peer and professional support throughout the recovery process.

Opportunity for dialogue. Group sessions should give the patient a chance to talk about recovery issues in a supportive environment where feedback from and discussion with people both more and less advanced in the recovery are available.

Involvement of others in problem solving. The group process should involve the patient in problem solving with other recovering people. The group leader can tell patients that others can and will help in problem solving if they are allowed to, that they too are capable of helping others, and that they can help themselves by helping others.

The principles of group counseling for patients recovering from addictions should be: Addiction groups. In order to be successful, groups must consist of only recovering alcoholics and drug addicts.

Group treatment goals with addicted patients. The addicted patient is suffering from chemical dependency. This is an illness causing specific physical, mental and social impairments. Group treatment must be directed at helping the patient with these impairments.

Structured and directive group process. The group process should be structured rather than free‑floating. Patients must focus on concrete, specific problem solving relating to accepting their addiction and achieving a comfortable recovery. Feelings should be dealt with in the context of these concrete problems. All problems dealt with in the group must be related to recovery from chemical dependency.

The role of the group counselor. The group counselor should be directive, yet permissive and supportive. The counselor is responsible for establishing and maintaining direction for each patient and for the group as a whole. The group counselor gives direction and supervision to the group. He or she must provide a consistent group format; set the pace of the group and see that it is maintained; assign, follow, and review assignments; and manage group problems as they develop.

The abstinence goal. The first focus of group treatment should be for each patient to establish and maintain abstinence from alcohol and mood‑altering drugs. This goal of recovery involves the identification of concrete problems and situations that could jeopardize abstinence, the development of specific plans for managing these problems, and the completion of skills training and assignments designed to develop skills in coping with these problems and situations.

Reliance on group support. Patients need to develop a strong substitute dependency to replace their old dependency on alcohol and drugs. Patients will tend to develop a strong dependency on the counselor as this substitute dependency. Group treatment should be used to transfer this dependency from the counselor to the group. Group counseling for addicted patients should be designed to support the patient's ongoing involvement in AA, NA, and other support groups. It should also focus on building strong, positive, supportive relationships among the group members.

Admission and discharge criteria. There should be specific admission criteria that describe the type of patient that is appropriate for treatment in group counseling. There should also be specific discharge criteria that describe when a patient is ready to responsibly “graduate" from the group.

Issues that are inappropriate for group treatment. There are certain issues that are best dealt with individually. This is due to the need for extreme confidentiality or a patient's inability to deal with the issues in a group setting. Care needs to be taken, however, not to support a patient's continuing denial by allowing him or her to avoid talking about routine recovery issues in group sessions.

Role modeling by the counselor. The counselor should model the behaviors that he or she expects from the patients.

Supportive counseling. The early efforts of the group counselor should be directed toward allying himself or herself with the addicted patient's needs rather than with attacking defenses. Addicted patients need basic support, education, communication training, and direction in recovery. These should be provided with support rather than harsh confrontation.

Group involvement. Eighty percent of the benefits of group treatment come from becoming actively involved in utilizing the group process to help other group members to recover. This involvement interrupts chemically dependent self‑centered behavior and provides training in the processes of problem solving and recovery. Many patients will automatically identify and discover solutions to problems in their lives by helping other patients cope with similar problems. Only 20 percent of the benefits of group counseling come from working on personal problems.

Note taking and tape recording in group. Addicted patients suffer from severe memory impairments. It is recommended that all patients take notes on important issues. Patients can also tape record portions of the group sessions where they work on an issue and receive feedback. Listening to these tapes later often speeds up the counseling process.

The intoxicated patient in group treatment. It is unproductive to allow a patient to attend group sessions while actively intoxicated with alcohol or drugs. The patient should be asked to leave the group and an individual appointment should be made to motivate the patient to enter appropriate detoxification treatment.

Rules and Contracting: Contracting is a tool that many groups use to help get members to attend meetings and follow rules. Because it is very important that all members agree to the requirements and rules of the group, a document can be written up and copied for each member and the group leader. Each member and the leader will sign this contract. The contract sets forth the day or dates of meetings, time, location and group rules.

Clearly stated and enforced rules are critical for a successful group. They can free members to deal with recovery issues. For example, when a rule of no violence is clearly stated and enforced, it allows the patient to feel and express anger, knowing that the group will not allow any one person to get out of control. Rules also offer limits to patients who have very few internal controls and who cannot set their own limits. Many substance abusers grew up in situations that did not teach them controls and limits. Establishing and enforcing group rules can help correct this.

Use the following guidelines in setting group rules.

• Do not make a rule that you or the agency cannot enforce.

• All rules must be enforced fairly and anytime they are violated.

• Rules should be clear and understood by all.

• Many substance abusers have memory problems; therefore, rules should be restated periodically and whenever a new member joins the group.

Group Rules: The following rules are designed to be used as part of the problem‑solving group process.

• You can say anything you want, any time you want to say it. Silence is not a virtue in this group and can be harmful to your recovery.

• You can refuse to answer any question or participate in any activity except the basic group responsibilities. The group cannot force you to participate, but group members do have the right to express how they feel about your silence or your choice not to get involved.

• What happens in the group stays among the members with one exception: Counselors may consult with other counselors in order to provide more effective treatment.

• No swearing, putting down, physical violence, or threat of violence.

• No dating, romantic involvement, or sexual involvement among the members of the group. Such activities can sabotage the treatment of those involved and others. If such involvements develop, members should bring it to the attention of the group or individual counselor at once.

• Anyone who decides to leave group treatment must tell the group in person prior to termination.

• Group sessions are 2 hours in duration. Patients should be on time and plan on not leaving the session before it is over.

• Smoking, eating, and drinking are not allowed in group sessions.

Responsibilities of patients in the group include the following:

• Listen to other group members' problems.

• Ask questions to help clarify problems or proposed solutions.

• Give feedback about what you think and feel about a problem and the personal strengths you see in the person that will help him or her solve the problem. Also give feedback about the weaknesses you see that may set the person up to fail to solve the problem.

• Share personal experiences with similar problems when appropriate. Self‑disclosure must be carefully managed to keep the primary focus on the patient who is working on the issue.

Resources of Interest:

• Alcoholics Anonymous (AA) @ www.aa.org

• Al-Anon & Alateen @ www.al-anon.org

• Cocaine Anonymous @ www.ca.org

• Narcotics Anonymous @ www.na.org

• Secular Organization for Sobriety

@ www.stillwatermall.com/sos

@ www.alcoholismhelp.com/help/editor/072098.html

• Rational Recovery

@ http://rational.org/

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