th
4
–
th
5
Step Workshop
Greg Gable, PsyD
Scott Teitelbaum, M.D., FASAM
Ken Thompson, M.D. , FASAM
Ken Thompson
INTRODUCTION
Introduction
• Relapse is associated with personality disorders in
physicians
• Depth and power of 12 steps often underestimated by
professionals
• 4th step gives clues to characterologic traits which are
formative of personality styling
• Relapse is associated with not doing a thorough 4th
step by self report
• 4th step is useful to process resentments, a known
relapse trigger
• Useful clinical information is gleaned from group 4th5th step work
Greg Gable
RELEVANT RESEARCH &
PSYCHOLOGICAL OBSERVATIONS
Relevant Research
 Risk factors for relapse included:



Family history of substance use disorder
Opiate use in the context of a comorbid psychiatric
disorder
Comorbid psychiatric disorder (Largely on Axis I)
Domino, Karen B. MD, MPH; Hornbein, Thomas F. MD; Polissar, Nayak L. PhD;
Renner, Ginger; Johnson, Jilda; Alberti, Scott; Hankes, Lynn MD, 2005
Relevant Research
• Cohort of 292 subjects
• 107 with comorbid diagnosis
– 100 with comorbid Axis I diagnosis
– 5 with comorbid Axis II diagnosis
– 2 with both
Domino, Karen B. MD, MPH; Hornbein, Thomas F. MD; Polissar, Nayak L. PhD;
Renner, Ginger; Johnson, Jilda; Alberti, Scott; Hankes, Lynn MD, 2005
Relevant Research
• 60.3% of assessed physicians suffered from
comorbid SUD and psychiatric disorders
• 56.8% with Axis II disorder
• 54.5% with Axis I mood disorders
• 34.1% combined
• 18.2% anxiety disorders
Angres, McGovern, Rawal, Purva, & Shaw,
2002
Relevant Research
• Physicians with comorbid diagnoses:
•
•
•
Did as well in treatment as controls
Seemed to have equivalent treatment outcomes at
follow up
Seemed to report greater degrees of emotional
distress even when engaged in a stable recovery
Angres, McGovern, Rawal, Purva, & Shaw,
2002
Relevant Research
• 308 physician cohort
• 78 physicians with relapse (25%)
• 230 physicians with no relapse (75%)
• 78 physician relapse population
• 55 physicians reengaged in monitored recovery
• 92% of original cohort in monitored recovery of at least
5 years
Gable 2002
Relevant Research
Time to First Relapse
Year of relapse f
 <1
11
 1-5
25
 5-10
10
 >10
4
Gable 2002
% _____
22%
48%
20%
8%_____
Drug of Choice
Relapse
Non-relapse
Opioid
23
46%
22
44%
Non-opioid
27
54%
28
56%
Gable 2002
Relapse Relevance
Condition
relapse
non-relapse
Abuse *
26
52%
22
45%
Family SUD
30
61%
37
75%
Eating Disorder
10
20%
11
21%
Compulsive Behaviors
_________________
15
30%
11
21%
* Emotional/Physical/Sexual Abuse
Gable 2002
Relapse Relevance
• The presence of an Axis II disorder was
strongly related to relapse
– (χ² = 16.071, df = 1, p<.05) (46% of the relapse group had an Axis II diagnosis,
compared to eight percent of the non-relapse group). (p actually computed as
.000)
Gable 2002
Relapse Relevance
Personality Disorder Diagnosis
Diagnosis
OCPD
relapse
4
8%
non-relapse
0
0%
NPD
2
4%
0
0%
BPD
2
4%
0
0%
PD NOS
15
30%
4
8%
Gable 2002
Relapse Relevance
• The presence of a comorbid Axis I
diagnosis was significantly related to
relapse
– ( χ² = 9.180, df = 1, p<.05). (p computed to .002)
Gable 2002
Relapse relevance
Axis I disorder
relapse
non-relapse
Bipolar
6
12%
1
2%
MDD
12
24%
7
14%
Dysthymic
1
2%
2
4%
Bulimia
3
6%
3
6%
PTSD
1
2%
1
2%
Anxiety/Panic
3
6%
0
0%
OCD
1
2%
0
0%
Sexual
1
2%
0
0%
ADHD
1
2%
0
0%
(43% of overall sample had a comorbid Axis I dx)
Gable 2002
Relapse Relapse
• When the presence of an Axis II disorder is
combined with the presence of an secondary
Axis I disorder (not including secondary
substance use disorder diagnoses), the
presence of a co-occurring psychiatric disorder
on Axis I or Axis II was strongly related to relapse
 (χ² = 23.645, df=1, p<.05). (p actually computed to .000)
Gable 2002
Relapse Relevance
Relapse Status
Relapse
No Relapse
f
41
17
% of group
82%
34%
Note: Comorbid secondary substance use
disorders are not included
Gable 2002
Project Match Data
• Compared CBT, MET, and TSF
• Months 4 to 15 Sobriety
– CBT = 15%
– MET = 14%
– TSF = 24%
• The advantage of TSF endured through the 12
month follow up period (NIAAA)
Personality/Relational Issues as
Relapse Factor
 Presence of relational difficulties presents barriers to
effective long-term use of tools
 Traits increase relapse risk because:
 Less assiduous use of tools
 Pt. can revert to pre-recovery coping mechanisms at
times of heightened emotional stimulation (positive or
negative)
 Learned use of tools over time can decay
Diagnostic Issues
• Danger in diagnosing personality disorder
too early in treatment process
• Danger in diverting patient focus from
addiction to “psychological issues”
• Tendency to postpone addressing of these
issues in favor of recovery tools/comparing
in.
Implications for Treatment/Recovery
• Trauma often a factor
• Important to help patient identify the trauma
and importance for working with it over time
• Important not to avoid trauma material in
treatment
• Unresolved/undisclosed trauma can prevent
honest sharing with others
Case Study Sarah
• Internist
• Treated in long-term residential
• Relapsed soon after to meds not covered on HP
panel (after researching this)
• Flew under radar for over a year, then relapse
became visible
• Returned to long-term residential treatment
• Personality issues, cluster B a problem in
treatment
Case Study Sarah
• Discharged early because of rule violations
• Struggled in outpatient, willful, not accepting
of treatment plan
• About 8 months after second tx experience,
began to show changes
• When interviewed, identified sponsor and 4th
step as change agent
Case Study Sarah
• Mary identified a character defect as having
been central to her difficulty in recovery
• When asked to name this defect, she did not
describe narcissistic, borderline or antisocial
traits.
• She talked about becoming aware of her
intolerance, lack of acceptance
• This construct was, for her, something to build
change upon.
Project Match Data
-Compared CBT, MET, and TSF
-Months 4 to 15 Sobriety
CBT = 15%
MET = 14%
TSF = 24%
The advantage of TSF endured through the 12 month follow up
period (NIAAA)
What we have learned
• Important to bring the traits into awareness
• Important to make work on the traits part of the
treatment/recovery plan
• Important for clinicians to communicate to other
providers about presence and potential effects of
traits
• Not important to have pt. arrive at acceptance of
a specific diagnosis
What have we learned?
• Identifying trauma and characterologic issues
early as possible is important
• 4th step and enneagram are helpful in bringing
relapse issues into the light
• It is not so important to diagnose except to
communicate with other treaters
• People are willing to get rid of things that they
deem as non-functional.
• On going attention to this by “monitoring” groups
might be important – group 4th step work and or
enneagrams might be useful
Scott Teitelbaum
DEPTH & POWER OF STEPS 4, 5, 6 & 7
Depth of the Steps
•
•
•
•
Underestimated by many professionals
More than just meetings
Ability to assess personality styling
Open the door to transformation of
personality
Spiritual Principles – Psychiatric Counterparts
•
•
•
•
•
•
•
•
•
•
•
•
Step 1 – honesty
Step 2 – hope
Step 3 – faith
Step 4 – courage
Step 5 – integrity
Step 6 – willingness
Step 7 – humility
Step 8 – brotherly love
Step 9 – justice
Step 10 – perseverance
Step 11 – spirituality
Step 12 – service
Resentments
• “For when harboring such feelings we shut
ourselves off from the sunlight of the Spirit.
The insanity of alcohol returns and we drink
again. And with us, to drink is to die”.
• Common cause of relapse
• Reflects a deep spiritual problem
• Fear and hurt underlie the anger
4th Step
•
•
•
•
Personal Inventory
Explores - resentments, fears, wounds, secrets
Looks for character defects to remove
Can be used as a diagnostic tool?
Ken Thompson
4TH STEP BY THE COLUMNS
4th Step – 4 columns
I’m resentful at
The cause
Affects my
Character defects
I’m resentful at
Father
Bob - peer
The cause
Affects my
Character defects
I’m resentful at
The cause
Father
Unemotional
High expectations
Never attended any of
my sports activities
Physically abusive
Bob
Attention to my wife
Did not pay money he
owed
Took my job
Affects my
Character defects
“ The Ouch”
“Spiritual Wound”
I’m resentful at
The cause
Affects my
Father
Unemotional
High expectations
Never attended any of
my sports activities
Always at work
Physically abusive
Self esteem
Sense of comfort
Security
Bob
Attention to my wife
Did not pay money he
owed
Took my job
Sex relations
Financial security
Character defects
Self centered fear
“ The Ouch”
“Spiritual Wound”
Personality Styling
I’m resentful at
The cause
Affects my
Character defects
Father
Unemotional
High expectations
Never attended any of
my sports activities
Always at work
Physically abusive
Self esteem
Sense of comfort
Security
Emotionally distant
Perfectionistic
Entitled
Bob
Attention to my wife
Did not pay money he
owed
Took my job
Sex relations
Financial security
Wrath, vengeful
Lust
Common Doctor Defects
•
•
•
•
•
•
Perfectionism
Care taking
People pleasing
Intellectualism
Arrogance-entitlement
Workaholism
Ken Thompson & Scott Teitelbaum
OBSERVATIONS
The Barriers to a 4th step
I’m resentful at
The cause
Affects my
Character defects
Father
Unemotional
High expectations
Never attended any of
my sports activities
Always at work
Physically abusive
Self esteem
Sense of comfort
Security
Emotional distant
Isolative
Arrogant
Entitled
Bob
Attention to my wife
Did not pay money he
owed
Took my job
Sex relations
Financial security
Wrath, vengeful
Lust
Greed
May not see the
resentment or
too ashamed to
address it
May negate the
resentment since they
realize they did something
wrong as well
Not emotionally connected
May not feel the
ouch
Not able to see
impact on security
Not able to see the
fear
May continue to justify
the behaviors Do not
see connection to
“wound”
Do not see them as still
active in life
CASE STUDIES
All of us
BARRIERS
Barriers
• Religious perceptions
• Morality as issue
• Lack of understanding of 12 steps
Greg Gable, Scott Teitelbaum, Ken Thompson
WHAT WE HAVE LEARNED
Diagnostic Issues
• Danger in diagnosing personality disorder
too early in treatment process
• Danger in diverting patient focus from
addiction to “psychological issues”
What we have learned
Character Defects
•
•
•
•
•
Require energy to maintain
Driven by “wound”
Create distress
Distress may look like anxiety, depression
Attempts to medicate is common (by client
but also by “psychiatrists”)
What we have learned
• Important to bring the traits/defects into
awareness
• Important to make work on the traits part of the
treatment/recovery plan
• Important for clinicians to communicate to other
providers about presence and potential effects of
traits/defects
• Not important to have pt. arrive at acceptance of
a specific diagnosis
What have we learned?
• Identifying trauma and characterologic issues
early as possible is important
• 4th step is helpful in bringing relapse issues
into the light
• People are willing to get rid of things that they
deem as rotten.
• On going attention to this by “monitoring”
groups might be important – group 4th 5th
step work
THE FUTURE
The Future
• Operationalizing group – captive audience in
monitored physician groups
• Encouragement of working steps – possible
reduction in relapse
• Ability to see changes in recovery trajectory
Operationalizing
• Method of the group
• Findings by consensus
• Measurable components of the 4th- 5th step
group