AMPHETAMINE‐TYPE STIMULANT USE Treatment Protocol for use by staff & clinicians working with ATS clients of Therapeutic Communities Lynne Magor‐Blatch Project Officer James A. Pitts Chief Executive Officer Odyssey House McGrath Foundation July 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non‐commercial use or use within your organisation. All other rights are reserved. Requests and enquiries concerning reproduction and rights should be addressed to the CEO, Odyssey House McGrath Foundation, PO Box 459, Campbelltown, NSW 2560. Page 2 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Contents Acknowledgements Project Background Who this Treatment Protocol has been designed for Required skills and knowledge Motivational Interviewing Framework Introduction Clinical criteria Clinical history Withdrawal Methamphetamine withdrawal Management of comorbid psychosis When and how to refer to mental health services Section 1: Clinical Assessment Comprehensive assessment Assessing readiness for change Mental health assessment Screening for depression and anxiety The PsyCheck Screening Tool Section 1: General mental health screen Section 2: Suicide/Self‐harm risk assessment Section 3: Self reporting questionnaire (SRQ) Screening for psychosis 5
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Section 2: Tip Sheets 1: Dose effects of amphetamines & Effects of methamphetamine use 31 2: Managing acute toxicity 32 3: Managing aggressive or agitated behaviour 33 4: Some facts about Cravings 34 5: Drug Treatment Metaphor 35 6: Pavlov’s Dog 36 7: The Bridge Concept 38 8: Managing your Feelings in Recovery 40 9: The Fight or Flight Response 42
10: Coping with Anxiety: Bodily Symptoms 44 11: (Changing) The Anxiety Cycle 45
12: Ten Most Common Relapse Dangers & High‐Risk Situations 46
© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 3 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Section 3: Treatment Modules 47
Treatment intervention Trial of Treatment Protocol: First Study Module 1: Building motivation for change Module 2: Understanding and coping with cravings Acceptance and Commitment Therapy (ACT)
Module 3: Understanding how thoughts influence behaviour Module 4: Understanding feelings and making the Mind/Body connection Module 5: Learning to deal with anxious thoughts and feelings Module 6: Understanding and acknowledging core beliefs and values Module 7: Relapse Prevention Section 4: Worksheets Worksheet 1: Timeline Follow Back Worksheet 2: Stages of Change Ladder Worksheet 3: Psychosis screener Worksheet 4: Lifestyle issues causing problems in my life Worksheet 5: Decisional balance Worksheet 6: Vitality vs. Suffering Worksheet 7: Vitality vs. Suffering Diary Worksheet 8: Unhelpful thinking patterns Worksheet 9: Self monitoring record Worksheet 10: Understanding how we experience Feelings Worksheet 11: Feelings of Anger, Loss, Shame and Guilt Worksheet 12: Pleasant Events Calendar Worksheet 13: Anxiety Anxious Automatic Thoughts Questionnaire Worksheet 14: Coping Statements for Anxiety Personal Values Card Sort Worksheet 15: Ranking of Personal Values Card Sort Worksheet 16: Personal Values Exercise Worksheet 17: Values ‘Bull’s Eye’ Worksheet 18: Cultivating Positive Affirmations and Vision Worksheet 19: My Relapse Dangers Worksheet 20: Problem Solving Worksheet 21: Relapse Prevention Plan References List of Tables Table 1. Risk levels and response to suicidality Table 2. Interpretation of the SRQ score Figure 1. Stages of change for initiation and cessation of (harmful) substance use 49
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Page 4 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Acknowledgements This Treatment Protocol has drawn on a number of sources, including: Baker, A., Kay‐Lambkin, F., Lee, N.K., Claire, M. & Jenner, L. (2003). A brief cognitive behavioural intervention for regular methamphetamine users. Canberra: Australian Government Department of Health and Ageing. Lee, N., Johns, L., Jenkinson, R., Johnston, J., Connolly, K., Hall, K. & Cash, R. (2007). Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No 14: Methamphetamine dependence and treatment. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc. The Treatment Protocol has been enhanced through attendance by the principal author at three valuable experiential workshops, from which information has been sourced and utilised with permission of the authors: • Liana Taylor, Mindfulness‐Based Cognitive Therapy, experiential intensive course and professional development, Canberra, 12 – 15 February, 2009. • Dr Chris Wagner, Adapting Motivational Interviewing to a Group Counselling Setting, Sydney, 9‐10 March, 2009. • Dr Russ Harris, ACT MINDFULLY: Acceptance & Commitment Therapy Training, Canberra, 23‐24 March, 2009. The authors also wish to acknowledge the valuable help and support of the following people who provided input through teaching, expert comment and critical appraisal in the development of this Treatment Protocol: Assoc. Professor Robert Ali Drug and Alcohol Services, South Australia Professor Amanda Baker NHMRC Research Fellow Centre for Brain and Mental Health Research, University of Newcastle Professor Jan Copeland Director, National Cannabis Prevention & Information Centre & Assistant Director, National Drug and Alcohol Research Centre Dr Russ Harris ACT MINDFULLY, Psychological Flexibility Pty Ltd Dr Nicole Lee Turning Point, Melbourne Dr Rebecca McKetin National Drug and Alcohol Research Centre, Sydney Dr Joel Porter Director, The Pacific Centre for Motivation & Change, New Zealand
Professor Debra Rickwood Head, Centre for Applied Psychology, University of Canberra Liana Taylor Co‐Founder, Director of Training, Mindfulness Centre, Adelaide Assoc. Professor Chris Wagner Virginia Commonwealth University, USA The authors would also like to thank representatives of the following Therapeutic Communities who contributed to the development of the Treatment Protocol through consultations in Australia and New Zealand: Queensland: Fairhaven, Goldbridge, Logan House, Mirikai, WHOS Najara New South Wales: Blue Mountains Recovery Services, The Buttery, Odyssey House, Selah Farm, The Peppers, WHOS, Wollongong Crisis Centre Victoria: Odyssey Vic, YSAS, YSAS Birribi, Windana Western Australia: Cyrenian House, Palmerston Farm, Serenity Lodge Australian Capital Territory: ADFACT/Karralika, Canberra Recovery Services, Ted Noffs Foundation Northern Territory: Drug and Alcohol Services Association, Alice Springs South Australia: The Woolshed, Kuitpo Community: UnitingCare Wesley Adelaide Inc. New Zealand: Higher Ground Trust, Odyssey House Auckland © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 5 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 6 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Project Background The Amphetamine‐type Stimulants (ATS) Grants Program was established by the Australian Government in 2008 to enhance the capacity of non‐government organisations (NGOs) to respond to the rising demand of users of ATS. The aim of the program is to reduce the harms caused by ATS to individuals, their families and the Australian community. This is intended to be one‐off funding to allow NGO’s to cater for and treat ATS users, to attract ATS users into treatment and/or to increase referrals of ATS users into treatment services. It is expected that treatment interventions funded through the ATS Grants program should: 1. Reduce and treat the use of illicit drugs; 2. Be informed by evidence and use models of good practice; 3. Reduce the risk of infectious disease; 4. Improve physiological and psychological health; 5. Reduce criminal behaviour; and 6. Improve social functioning. Odyssey House McGrath Foundation was successful in gaining funding support to develop a treatment protocol for people who are adversely affected due to their use of ATS. While the treatment protocol will be specific for use in the Therapeutic Community (TC) environment, it is anticipated that the protocol will also be useful in other treatment settings, including residential treatment environments and outpatient settings. The project has been conceptualised in three stages: Stage 1: A literature review outlining background issues, problems associated with ATS use and current available treatment interventions. Stage 2: Consultation with members of the National Drug and Alcohol Research Centre and other research institutes with expertise in research on ATS. : Consultation with members of the Australasian Therapeutic Communities Association (ATCA) through forums organised at jurisdictional level, including New Zealand. Stage 3: Development of the treatment protocol for people dependent on ATS in a TC environment. This has been undertaken in two phases – the development of a draft protocol, trialled and evaluated within selected TCs; and the development of the final protocol following refinement through consultation and evaluation. Contained within this treatment package are two documents. The first, Literature Review, Report of Consultations and Trial in the Development of a Treatment Protocol for clients of Therapeutic Communities (Magor‐Blatch & Pitts, 2009), provides a review of the national and international literature in relation to treatment for clients with ATS dependencies, an overview of therapeutic communities and report of consultations in Australia and New Zealand with TCs, practitioners and researchers. Included in the report is information on the development of treatment interventions in Australia and report of Australian studies focussing on ATS users. The final section in this report provides results from the initial trial of the Treatment Protocol with clients of Mirikai on the Queensland Gold Coast and Cyrenian House in Perth, Western Australia. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 7 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities The Treatment Protocol for use by staff & clinicians working with ATS clients of Therapeutic Communities has been developed after extensive consultations with those working with ATS clients in therapeutic communities in Australia and New Zealand, research institutes and others with expertise in research, clinical practice and the development of clinical interventions. The following protocol draws heavily on both the collected information from consultations and on other treatment manuals, interventions and guidelines which have been developed within Australia and overseas in working with this client group. We are grateful to the researchers and authors who have provided permission for the use of this material. When the project first commenced, we believed we would be developing a ‘protocol’ which outlined a procedure for use by staff – a treatment manual rather than treatment guidelines. During the consultation process, it became clearer that while a manualised approach, or ‘protocol’ remained an important resource for staff of TCs, a series of ‘tip sheets’ and materials that could be added to the package and used flexibly would be of great overall value. Therefore the original concept has changed to some extent. While the Treatment Protocol for use by staff & clinicians working with ATS clients of Therapeutic Communities includes a manualised intervention, the package also contains information which can be used flexibly in working with clients within the TC setting. Also included are Tip Sheets and activities for staff and clients to assist in understanding and working with the sometimes complex behaviours and issues relating to mental health problems that can be experienced by clients who have been using ATS and other substances. Tip Sheets also form a resource for families and professionals both within and outside the TC to help them better understand some of the issues and to develop strategies which may assist in dealing with complex clients, both on a personal and professional level. Lynne Magor‐Blatch MAPS, MCFP B.A. (Hum. & Soc.Sci.); M.Psych (Forensic); Grad.Dip.App.Psych. Dip.Teach. (Sec); Cert IV TAA Project Officer James A. Pitts MA Chief Executive Officer Page 8 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Who this Treatment Protocol has been designed for The Treatment Protocol for use by staff & clinicians working with ATS clients of Therapeutic Communities has been developed after consultation for staff and clinicians working within Therapeutic Communities (TCs) and associated programs. While the prime focus of the material contained within this treatment package is clients with problems associated with the use of Amphetamine‐Type Stimulants (ATS), it is recognised that many clients within TCs are experiencing an array of problems, and particularly mental health problems, resulting from the use of a range of substances. Therefore, it is anticipated that the material contained in this treatment package will also be of use to staff who are working with clients with complex behaviours resulting not only from ATS use, but also from other substance use, either in combination or in isolation. Staff and clinicians utilising this material are also encouraged to access and consider other materials which have been developed both in Australia and overseas. Research into ATS use is continuing and information about treatment interventions will continue to be developed as the results of further studies become available. Required skills and knowledge It is expected that all staff and clinicians within TCs will have experience in working with clients with complex behaviours utilising the TC tools and treatment modality. TCs differ from other treatment approaches principally in their use of the community, comprising treatment staff and those in recovery, as key agents of change. This approach is referred to as ‘community‐as‐method’. TC members interact in structured and unstructured ways to influence attitudes, perceptions, and behaviours which are considered to be associated with substance use. In addition to the importance of the community as a primary agent of change, other fundamental TC principles are ‘self‐help’ and ‘mutual help’. Self‐help infers that clients are responsible for participating and contributing to the TC process to change their behaviours. By mutual help, we mean that clients assume responsibility for helping their peers. Both concepts of mutual and self‐help reinforce the recovery process. The unique aspects of the TC as a modality were an important consideration in the development of the treatment package. While we have certainly utilised and ‘borrowed’ from the many excellent interventions which have already been developed, the focus has been very much on working with clients within a group setting, which is the hallmark of TC treatment. However, as all TCs provide the opportunity for both individual and group counselling, depending on the need of the individual and of the community, the Treatment Protocol has been designed for both applications. In the consultation process, a number of different treatment interventions were reviewed and suggested. These included interventions based on the use of Cognitive Behavioural Therapy (CBT), Motivational Interviewing (MI), Mindfulness‐based interventions (Mindfulness‐based Stress Reduction (MBSR) and Mindfulness‐based Cognitive Therapy (MBCT)), Acceptance Commitment Therapy (ACT) and other therapeutic interventions. The Treatment Protocol and associated materials within the treatment package have utilised strategies from all of these interventions. Some will already be known to staff and clinicians, others will be new. Training in the use of the materials within this package will be provided as part of the implementation process for the project. Included in the treatment package, are a number of suggested activities and exercises, together with Tip Sheets and ideas for additional therapeutic interventions. Staff who are not trained in their use should undertake training before practising the suggested activities or treatment interventions. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 9 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities It needs to be acknowledged that some clients with mental health problems, including comorbidity associated with their ATS use, may be vulnerable and at risk. Therefore it is important that staff only utilise those interventions with which they feel confident, and in which they have been trained. Motivational Interviewing Framework Motivational Interviewing is a client‐centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. While the first module of the Treatment Protocol specifically focuses on building motivation for change, the protocol is embedded in the use of motivational interactions and techniques. Information and literature on the use of motivational interviewing with groups is in the evolving stages. Dr Chris Wagner and his colleagues, Karen Ingersoll and Sandra Gharib have co‐authored Motivational Groups for Community Substance Abuse Programs, and another book is currently in production. In the development of this treatment intervention, the principal author attended a workshop facilitated by Dr Chris Wagner and supported by Dr Joel Porter, Director of the Pacific Centre for Motivation and Change. This was invaluable in helping to synthesise the ideas around the way in which the protocol should be delivered. Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be. The use of motivational interviewing techniques within the group setting should therefore seek to enhance and focus the client's attention on such discrepancies with regard to their drug use. The first module of the protocol develops this discrepancy by raising the client's awareness of the adverse personal consequences of his or her drug use. This information, properly presented, can precipitate a crisis of motivation for change. As a result, the person may be more willing to enter into a discussion of change options, in order to reduce the perceived discrepancy and regain emotional balance (Miller, 1995). Motivational Interviewing (MI) is not a ‘treatment’ but a way of ‘being with’ (Dr Chris Wagner, the use of MI with Groups Training Workshop, Sydney 9‐10 March, 2009). The group core concepts (presented by Dr Wagner) are: 1. Therapeutic Factors – Hope, Universality, Altruism, Information, Socialising (Inspiration, Support); 2. Interpersonal Learning – Relationships, Corrective emotional experience, Group as a social microcosm; 3. Therapist tasks ‐ Shaping norms, Working in the here‐and‐now, Utilising process orientation; and 4. Person‐centred groups: a. Growth conditions: Genuineness, Acceptance, Empathy b. Person‐centred vs. Expert leader groups c. Rogers’ group stages/process patterns – Unfocused; Past feelings; Present individual feelings and concerns; Interpersonal engagement between group members; Reduction in defences; Opening to new experiences; Deepening; New ways of being The use of MI with groups draws on techniques used in individual therapy. Both build motivation to change by helping people to become ‘unstuck’; both balance client‐centred and directive elements; both use the same communication style and strategies; and both avoid non‐adherent clinical behaviours (Dr Chris Wagner, MI with Groups Workshop, 9‐10 March, 2009). The differences essentially lay in the dynamics of the group – managing ‘floor time’, different styles and beliefs across members, eliciting group energy for change, working with group members to facilitate communication and balancing the facilitation vs. interviewing processes. The group setting Page 10 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities is not meant to be a series of individual conversations or therapy sessions, but a process whereby all members are included to support and challenge ideas. Dr Wagner, in presenting the MI with Groups workshop, drew out the following in the facilitation of MI groups: a. Focus on positives b. Bring the group into the moment c. Explore perspectives and focus on the present d. Hear complaints, but do not elicit grievances e. Broaden perspectives and focus on the future f. Reflect and explore positive focus on desires, needs, plans and self g. Counteract any negative reactions before the session ends The group tasks therefore will include engaging and exploring issues, including values and ambivalence; broadening and building interest and confidence in changing; and helping members plan steps towards a commitment for change. These are the important processes to maintain in the presentation of the following treatment intervention. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 11 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 12 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Introduction Amphetamine‐Type Stimulants (ATS) are part of the psychostimulant group of drugs and include meth/amphetamine, ecstasy, cocaine and some pharmaceuticals (such as dexamphetamine and Ritalin). Methamphetamine comes in three common forms: powder (or ‘speed’), methamphetamine base (or ‘base’) and crystal methamphetamine (or ‘Ice’). Ecstasy is usually in tablet form and contains 3,4‐methylenedioxymethylamphetamine (MDMA) in varying amounts combined with other drugs such as meth/amphetamine1 and ketamine (a general dissociative anaesthetic). In Australia, the main ATS used are methamphetamine and ecstasy (National Amphetamine‐Type Stimulant Strategy, 2008‐2011). ATS stimulate central nervous system activity by increasing synaptic concentrations of three major neurotransmitters in the brain: dopamine, serotonin (5‐HT) and noradrenaline (Rothman & Baumann, 2003). This has the effect of producing a euphoric sense of wellbeing, wakefulness and alertness. Use of ATS is also associated with a range of potentially negative health consequences, including increased heart rate, blood pressure, sleeplessness and reduced appetite. There is also greater risk of mental health issues, aggression, violence and accident resulting from unsafe behaviours, such as unsafe driving. Therefore methamphetamine use can be associated with a range of both positive and negative effects. Positive effects include: • euphoria; • increased libido; • alertness; • diminished appetite; • enhanced reflexes; and • feelings of confidence and physical strength (ACON, 2006). Negative effects include: • increased heart rate and irregular heart beat; • abdominal pain; • sweating; • dilated pupils; • fatigue; • parasitosis (picking and scratching skin); • agitation, anxiety and paranoia; • confusion, disorientation and hallucinations; • psychosis; and • violent and aggressive behaviour (ACON, 2006). A large proportion of ATS dependent users will experience psychological problems. These will include depression, anxiety and psychosis. Meth/amphetamine intoxication, particularly where there is simultaneous use with alcohol and other drugs, often results in agitation and aggression and will impact on frontline workers and families. This leads to significant resource implications for workers and organisations, including law enforcement, mental health and alcohol and other drug (AOD) services. The impact on families may also be dramatic, raising the need to support all family members as well as the person using ATS. 1
Meth/amphetamine is used to refer to amphetamine and methamphetamine in instances where both forms are relevant. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 13 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities The following Tip Sheets are included with this treatment package, and may be provided to clients, family members and others who are supporting the person. These will provide some information to help each person understand the possible symptoms resulting from ATS use and withdrawal: • Tip Sheet 1: Dose effects of amphetamines & Effects of methamphetamine use • Tip Sheet 2: Managing acute toxicity • Tip Sheet 3: Managing aggressive or agitated behaviour Clinical criteria According to the Diagnostic and Statistical Manual of Mental Disorders IV‐TR (DSM‐IV‐TR) dependence is characterised by a person experiencing at least three of the following symptoms: • tolerance, defined as either a need to use larger amounts to achieve desired effect, or decreased effect with continued use of the same amount of substance; • withdrawal; • increased dosage and duration of the substance use; • unsuccessful attempts to cut down or control substance use; • increased time spent to obtain the substance, use the drug or come down from the drug; • giving up social, occupational and recreational activities because of substance use; and • continued substance use despite knowledge of having an awareness of negative consequences (e.g., physical or psychological problems) (American Psychiatric Association (APA), 2000) Additionally, the DSM‐IV‐TR (APA, 2000) provides a diagnostic criteria for amphetamine intoxication: A. The patient has recently used an amphetamine or related substance, such as methylphenidate. B. Clinically significant maladaptive behavioural or psychological changes developed during or shortly after the patient used amphetamines or a related substance. Such changes include the following: Euphoria or affective blunting Changes in sociability Hypervigilance Interpersonal sensitivity Anxiety, tension, or anger Stereotyped behaviours Impaired judgment Impaired social or occupational functioning C. Two or more of the following conditions develop during or shortly after the patient used amphetamines or a related substance: Tachycardia or bradycardia Pupillary dilatation Elevated or lowered blood pressure Perspiration or chills Nausea or vomiting Evidence of weight loss Psychomotor agitation or retardation Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias Disorientation and memory loss, seizures, dyskinesias, dystonias, or coma D. The symptoms are not due to a general medical condition, and another mental disorder does not account for them better than amphetamine intoxication does. Page 14 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities The DSM‐IV‐TR (APA, 2000) also describes the following 10 amphetamine‐related psychiatric disorders: 1. Amphetamine‐induced anxiety disorder 2. Amphetamine‐induced mood disorder 3. Amphetamine‐induced psychotic disorder with delusions 4. Amphetamine‐induced psychotic disorder with hallucinations 5. Amphetamine‐induced sexual dysfunction 6. Amphetamine‐induced sleep disorder 7. Amphetamine intoxication 8. Amphetamine intoxication delirium 9. Amphetamine withdrawal 10. Amphetamine‐related disorder not otherwise specified Either prescription or illegally manufactured amphetamines can induce these disorders. Prescription amphetamines are used frequently with children and adolescents to treat attention deficit hyperactivity disorder (ADHD), and they are the most commonly prescribed medications for children. Amphetamine‐related psychiatric disorders are conditions resulting from intoxication or long‐term use of amphetamines or Amphetamine‐type Stimulants (ATS). These disorders can also be experienced during the withdrawal period and are often self‐limiting after cessation, though, in some cases, psychiatric symptoms may last several weeks after discontinuation. This is particularly important for treatment agencies to understand, since it is often after the person has been accepted into treatment in, for example, a therapeutic community, that symptoms present. For some people, this will include paranoia during withdrawal as well as during sustained use. Amphetamine use may also elicit or be associated with the recurrence of other psychiatric disorders. People addicted to amphetamines sometimes decrease their use after experiencing paranoia and auditory and visual hallucinations (Larson, 2008). The symptoms of amphetamine‐induced psychiatric disorders can be differentiated from those of related primary psychiatric disorders by time. If symptoms have not resolved within two weeks after discontinuation of ATS, it is advised that a primary psychiatric disorder should be suspected (Larson, 2008). Depending on the severity of symptoms, symptomatic treatment can be delayed to clarify the etiology. However, it is important that TCs gain the support of mental health services and consult with a psychiatrist to better assess problems related to ATS use and withdrawal. Amphetamine‐induced psychosis (delusions and hallucinations) can be differentiated from psychotic disorders when symptoms resolve after ATS withdrawal. Absence of symptoms, including anhedonia (the inability to gain pleasure from enjoyable experiences), avolition (a psychological state characterised by general lack of desire, drive, or motivation to pursue meaningful goals), amotivation (the inability or unwillingness to participate in normal social situation), and flat affect, are further indicators of amphetamine‐induced psychosis (Larson, 2008). Amphetamine‐induced delirium follows a reversible course similar to other causes of delirium, and it is identified by its relationship to amphetamine intoxication. After the delirium subsides, little to no impairment is observed. Delirium is not a condition which has been observed during amphetamine withdrawal (Larson, 2008). Mood disorders similar to hypomania and mania may be observed during ATS intoxication. Depression may also result during withdrawal, and repeated use of ATS can produce antidepressant‐
© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 15 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities resistant amphetamine‐induced depression. Sleep disturbances may be evident, and these will appear in a fashion similar to mood disorders (Larson, 2008). During intoxication, sleep can be decreased markedly. This was observed by many of the TCs during the consultation process as being one of the concerns in the early stages of treatment, with the after‐effect, being the need for more sleep. This is part of the withdrawal process. A disrupted circadian rhythm can result from late or high doses of ATS. Amphetamine‐related disorder not otherwise specified is a diagnosis assigned to those who have several psychiatric symptoms associated with amphetamine use but do not meet the criteria for a specific amphetamine‐related psychiatric disorder (APA, 2000). Clinical history Amphetamine‐related psychiatric disorders can be confused with psychiatric disorders caused by organic, medical, neurologic, and/or psychological etiologies. The causes of amphetamine‐related psychiatric disorders may be determined by assessing the client's history and developing a genogram. The DSM‐IV‐TR (APA, 2000) provides criteria helpful for determining if the person is in a state of intoxication or withdrawal. The criteria helps clinicians distinguish disorders occurring during intoxication (e.g., psychosis, delirium, mania, anxiety, insomnia) from those occurring during withdrawal (e.g., depression, hypersomnia). 1. Developmental history: The developmental history provides information about the client's in utero exposure to medications, illicit drugs, alcohol, pathogens, and trauma. o
As children, clients may have had prodromal symptoms of psychiatric disorders, such as social isolation, deteriorating school performance, amotivation, avolition, anhedonia, sleep disturbances, sexual paraphilias, poor interest, psychomotor retardation, demoralisation, social isolation, and suicidal thoughts and behaviours. o Delinquency, truancy, educational failure, early use of drugs and alcohol, oppositional behaviour associated with conduct disorder, and use of ATS are developmental behaviours that suggest an amphetamine‐related psychiatric disorder. 2. Psychiatric history: Two issues are emphasised: o Determine whether a psychiatric disorder or symptoms ever occurred when the client was not exposed to amphetamines. o Determine whether the client ever had a psychiatric disorder or symptoms similar to the present symptoms in relation to any other drug or medication. 3. Recent history: The client's history of ATS use is the most important factor and is determined by asking the following questions: o When did ATS use start? o What is the nature of ATS use (e.g., speed, methamphetamine, and if so, what type?) o How often does the person use ATS? o How much is being used? o Is the person currently intoxicated or in withdrawal? o Has the client recently increased his or her ATS use or started to binge? Page 16 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Substance abuse history: Take a full substance use history. 5. Family history: A family history of a psychiatric disorder may suggest a primary psychiatric disorder. A diagnosis of amphetamine‐related psychiatric disorder might still be possible if the client has no family history of psychiatric disorder. 4.
Withdrawal The DSM‐IV‐TR (APA, 2000) criteria for amphetamine withdrawal are as follows: A. Cessation of (or reduction in) use that has been heavy or prolonged. B. Dysphoric mood and two (or more) of the following physiological changes developing within a few hours to several days after Criterion A: 1. Fatigue 2. Vivid, unpleasant dreams 3. Insomnia or hypersomnia 4. Increased appetite 5. Psychomotor retardation or agitation C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to a general medical condition, and are not better accounted for by another mental disorder. Methamphetamine withdrawal Lee and associates (2007) in Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No 14: Methamphetamine dependence and treatment, detail methamphetamine withdrawal syndrome as predominantly characterised by adverse psychological symptoms, such as extreme fatigue and irritability. The DSM‐IV‐TR characterises methamphetamine withdrawal as including dysphoric mood (sadness) plus two of the following: • fatigue • insomnia • hypersomnia (over‐sleeping) • psychomotor agitation • increased appetite • vivid, unpleasant dreams (APA, 2000). Drug cravings, paranoid or suspicious thoughts, and feeling angry, aggressive or emotional are other symptoms commonly associated with methamphetamine withdrawal. Withdrawal symptoms from methamphetamine may mimic the symptoms of acute intoxication, particularly agitation and hyper‐
arousal (Jenner & Saunders, 2004). While there is some evidence to suggest that the majority of symptoms of withdrawal will resolve within a week of ceasing methamphetamine use, with sleep and appetite related symptoms persisting for a further one to two weeks (McGregor, Srisurapanont, Jittiwutikarn, Laobhripatr, et. al., 2005) this may be influenced by a number of factors: • age (older and more dependent users may experience a more severe withdrawal) • general health • mode of administration • quantity and purity of methamphetamine being used prior to cessation • polydrug use © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 17 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Anecdotal evidence from the consultation process with TCs suggests symptoms of withdrawal may persist for longer periods, with the consensus being that clients may experience symptoms for up to four to six weeks, and that up to the first 12 weeks of treatment may be adversely affected. Dependent users are also likely to undergo withdrawal many times as use fluctuates between heavy use, regular use and periods of intermittent or binge use. Self‐detoxification is common and polydrug use by ATS users may serve the purpose of managing some of this process. TCs are amongst the specialist services that are most likely to see methamphetamine users who have suffered from depression, experienced psychotic symptoms such as hallucinations and paranoia, or have experienced behavioural problems, such as aggressive outbursts. All of these behaviours were reported as part of the consultation process. These clients require skilled clinicians and a range of resources in order to manage these complexities. Management of comorbid psychosis A small, but significant percentage of users will experience methamphetamine‐induced psychosis. Typically, this will occur following heavy binge or prolonged use, however, little is known about Australian prevalence rates (Dawe & McKetin, 2004). Lee and associates (2007) report that symptoms of a methamphetamine‐induced psychosis usually resolve within a few days after ceasing use. Nevertheless, this can be an extremely stressful event, with clients worrying that their use of methamphetamine may lead to a permanent psychotic disorder. During the consultations some TCs reported this occurrence, sometimes leading to clients being treated by mental health teams and in some cases, being admitted to psychiatric care for a period of time before returning to the TC. Clinicians should be aware that a period of abstinence (from methamphetamine) and improved self‐
care is likely to alleviate many symptoms without psychiatric intervention. However, in a small group of users, symptoms may worsen immediately after cessation of methamphetamine use (during withdrawal) but usually settle over a relatively short period of time – a matter of days or weeks (Lee, et.al., 2007). If symptoms resolve within a month of ceasing methamphetamine use, it is likely to have been a drug‐induced psychosis. For others, psychotic symptoms may persist for a longer period of a month or more (Dawe & McKetin, 2004). This may suggest a more enduring psychiatric condition. The issue of whether or not the symptoms of psychosis have been triggered by methamphetamine or other drug use, or whether there was a pre‐existing vulnerability to schizophrenia has often concerned those working in both the AOD and mental health fields (Dawe & McKetin, 2004). In the acute phase, this issue is not of immediate concern. At this point, the presenting symptoms rather than the underlying cause are the treatment focus. If psychotic symptoms worsen during treatment, then it is likely that there is an underlying mental health issue and psychiatric assessment and intervention may be required. Acute symptoms should be managed as a priority (Lee, et.al., 2007). A number of TCs reported having clients on ongoing anti‐psychotic medications where symptoms had not abated, and in some cases had increased. Once medication is stabilised, the person is generally able to continue within the TC and to take part in all program interventions. The treatment protocol should be offered once the symptoms of psychosis have resolved. Page 18 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities When and how to refer to mental health services All TCs in the consultation reported having professional relationships, including Memoranda of Understanding, with mental health services. Many had a consultant psychiatrist as part of the program clinical team. Lee and colleagues (2007) note there are four main reasons for making contact with a mental health service on behalf of a client. These are: 1. If it is suspected that the client has an undiagnosed or untreated psychotic disorder. For example, if the client appears to hear or see things that others don’t (hallucinations) or to hold delusional beliefs or to demonstrate bizarre behaviour – especially if these symptoms persist after a period of detoxification and stabilisation. 2. If there is a concern that the client has an undiagnosed or untreated bipolar disorder, as indicated by the presence of manic symptoms such as a decreased need for sleep or food, a marked period of productivity, a rapid flow of thoughts or speech and an exaggerated sense of self‐esteem or invincibility. 3. If there is a concern or a high risk of suicide or self‐harm. 4. If there is a concern about the person’s ability to respond to treatment. All TCs reported staff had an improved ability to respond to comorbid presentations, and all reported a level of mental health training. Nevertheless, the need to maintain specialist service relationships was seen as both a concern and a priority by all during the consultation phase. Of particular concern for TCs was a belief that in some cases mental health services had possibly viewed the TC as a ‘safe place’ for the client and therefore, after assessment, the intervention which the TC had expected, had not been delivered. This did not necessarily mean removal of the person from the TC into mental health care, but a better process of joint case management between the TC and mental health services. Balancing the needs of the individual against those of the community when a crisis occurs was reported as a concern for many TCs. The need for better communication between mental health and TCs was therefore cited as a priority. Included in this is the need to educate mental health and other medical services about the capacity of TCs to respond to crisis situations and to work with people with comorbid presentations. It is clear that TCs do work with very chaotic and complex clients. However, all noted that the balance within the community, including the numbers of clients within the program with complex behaviours, is something which needs to be continually monitored. This is especially important in the early stages of treatment, since it is likely that TCs will primarily deal with these issues during this phase. Hence there is a concern expressed by TCs regarding the number of clients and their degree of complexity in relation to comorbidity concerns, which the TC can admit and adequately treat, at any one time. The point at which clients often stabilise is also the point at which they may move to the second stage of the program. Therefore it is during the early treatment phase that TCs require increased support. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 19 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 20 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Section 1: Clinical Assessment © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 21 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 22 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Comprehensive assessment Conducting a comprehensive assessment is the first important step in developing a treatment plan for the client. It provides a baseline of information from which treatment can be designed and implemented. All TCs currently have in place an assessment process and protocol which have been designed to meet their needs. This treatment package will not therefore duplicate any of this general material, but will provide some additional materials which may be used to assist assessment. Also provided is a mental health assessment format for consideration. However, TCs that have already adopted the PsyCheck materials will be familiar with this material and others may already have in place assessment formats to collect the information. Where these are not already in place, it would be useful to review current materials in relation to those provided within this treatment package. The majority of people who use methamphetamines are polydrug users, and therefore ATS use is seen in conjunction with other drug use. As reported as part of the consultation process, mental health symptoms are common and at least require screening for all methamphetamine users. Engagement is often cited as a barrier to treatment for methamphetamine users, therefore it is important to assess readiness for treatment as part of this process (Lee, et.al., 2007). Lee and colleagues (2007) outline the necessary core elements of the drug use component of assessment for methamphetamine users as including: • accurate information about all aspects of methamphetamine use • indicators of severity of dependence, withdrawal symptoms and significant periods of abstinence • evidence of dependence on, or withdrawal from other drugs • risk behaviour associated with mixing drugs, including overdose or toxicity • psychosocial factors • treatment goals The assessment or clinical interview is also important in order to gather accurate information about: • type/s of methamphetamine being used • the quantity and frequency of use • the route of administration • duration of use The differences in drug use patterns between Australian and New Zealand ATS users, and particularly methamphetamine users, were evident during the consultation process. It is important to gather information about polydrug use, with a particular emphasis on the pattern of drug use in relation to methamphetamine use, such as mixing other drugs with methamphetamines and using other drugs (particularly depressants) to alleviate the ‘come down’ effects of methamphetamine. Lee and colleagues (2007) provide a timeline follow back (TLFB) worksheet as a validated method of understanding the recent pattern of drug use in relation to methamphetamine use, which may be used in conjunction with the clinical interview (see Worksheet 1: Timeline follow back). This is a calendar that records the last 30 days of use and may be of particular benefit with clients during the assessment and pre‐admission stage of treatment. It is suggested that anchors for the client should be provided by indicating public holidays, significant personal events and other dates on the calendar. The client should then be assisted to work back from the last day of use and complete information about all drug use for each day. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 23 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Assessing readiness for change All TCs will be familiar with the Stages of Change Model and the use of Motivational Interviewing in assessing the client’s readiness for change. While the client may already have completed detoxification prior to engagement with the TC, it is particularly important to explore readiness for change and other factors that may impact on the person’s engagement in the treatment process within the TC. Explore the client’s concerns or reservations they have about ongoing treatment and the treatment setting. Worksheet 2: Stages of change ladder can be used to discuss readiness to change with the client (adapted from Biener & Abrams, 1991 cited in Lee, et.al., 2007). The worksheet is specifically aimed at the person’s use of ATS and therefore assesses readiness to enter the TC, rather than as an indication of readiness to address general concerns about all substance use or to complete the TC or other AOD program. The ladder may be adapted to reflect the person’s movement through the TC program as part of a stepped‐care process. Monitor engagement closely throughout treatment and adapt interventions accordingly. Motivational enhancement and assessment techniques may be useful and are provided as part of the Treatment Protocol. Mental health assessment The high incidence of mental health problems amongst methamphetamine users has been well documented in the literature and further developed in the Literature Review and Report of Consultations (Stages 1 & 2) in the Development of a Treatment Protocol for clients of Therapeutic Communities (Magor‐Blatch, 2009) contained within this treatment package. All consultations highlighted the need for a comprehensive assessment process, including the recommendation that assessment staff and clinicians develop the skills to effectively assess and manage comorbidity within the TC client population. As part of this, there was an agreement and recognition that addressing both conditions as part of a coordinated approach was far more efficacious than treating each separately or in parallel. Baker, Kay‐Lambkin, Lee, Claire and Jenner (2003) recommend a comprehensive mental health assessment that focuses on: • identifying symptoms of depression, anxiety and psychosis (the most common psychiatric symptoms associated with methamphetamine use) • the duration of symptoms • whether symptoms are present during use or persist after methamphetamine use has ceased • previous treatment for mental health problems An assessment of the comorbidity of substance use disorder and psychiatric illness should therefore be conducted using the following prompts: • Consider the range of symptoms caused by each identified substance. • Determine whether substance use predated the psychiatric symptoms, using questions such as: o How old were you when you first experienced (symptoms)? o How old were you when you started using (substance) regularly (at least weekly)? • Determine duration and patterns of use and affect on psychiatric symptoms, using questions such as: o Has there been a time when you have not used (substance)? o If yes, how long was this for and how did this affect your symptoms? Page 24 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities •
Determine duration and patterns of psychiatric symptoms and affect on substance use, using questions such as: o Has there been a time when you have not experienced (symptoms)? o If yes, how did this affect your use of (substance)? Adapted from Dawe & McKetin (2004) in Lee, et. al., 2007. Screening for depression and anxiety The PsyCheck Screening Tool is an instrument that can be used to screen for high prevalence mental health problems among alcohol and other drug populations, as well as address the most prevalent disorders among amphetamine users. It is already being used by a number of TCs and has the benefit of an accompanying four‐session intervention to assist clinicians to manage depression and anxiety symptoms among AOD clients. Some of the TCs in the consultation, e.g., WHOs and Cyrenian House, have already adapted the four session intervention into a group format, for use with TC populations. The PsyCheck intervention is not reproduced here, and enquiries regarding its use should be directed to the Australian Government, Department of Health and Ageing. The Screening Tool is outlined below. All TCs report already having a mental health assessment tool in place, either as a stand‐
alone instrument or embedded within the main assessment protocol. It is important that information gathered as part of this process is able to be translated into an intervention, should information from the assessment indicate this need. The PsyCheck Screening Tool is particularly useful in this regard, since it very clearly articulates into an intervention according to scores achieved through the screening process. The PsyCheck Screening Tool The PsyCheck Screening Tool is a mental health screening instrument designed for use by clinicians who are not mental health specialists. It detects the likely presence of mental health symptoms that are often seen within AOD treatment services, and may be addressed without the specialist interventions of mental health professionals. As PsyCheck is not designed as a diagnostic assessment it will not yield information about specific disorders. It is designed to detect potential mental health problems that may be missed if they are not specifically investigated by the assessment or clinical staff or raised by the client. For this reason, it is considered important that all clients are given the screening instrument, even if they do not appear to have a mental health problem. Some TCs in the consultation have embedded Sections 1 and 2 within their assessment protocols and administer Section 3 soon after the person is admitted into the TC. The PsyCheck Screening Tool has three sections and can be used at any point in the assessment and treatment of a client once they are stabilised (i.e., no withdrawal symptoms and/or stabilised on pharmacotherapy). As noted, it can be readily incorporated into the regular assessments conducted at entry to services and should also be re‐administered throughout treatment, whenever other reviews of progress are conducted (Lee, et.al., 2007). The Self Reporting Questionnaire (SRQ) can be self or clinician administered, while the other sections are administered by the clinician. If used as a stand‐alone screening tool, it may not be necessary to go through all the questions if some of the information (for example, hospitalisation, past history) has already been collected. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 25 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Section 1: General mental health screen Section 1 of the PsyCheck has five questions designed to identify clients who have been previously diagnosed or treated for mental health problems. Question 5 in Section 1 of the PsyCheck is a prompt for the presence of suicidal ideation: ‘Has the thought of ending your life ever been on your mind?’ If the client answers ‘Yes’, a full suicide/self‐harm risk assessment is conducted as indicated in Section 2 of the PsyCheck. Section 2: Suicide/Self‐harm risk assessment If the client answered ‘Yes’ to suicide ideation in Section 1, a full suicide/self‐harm risk assessment is required. Assessment staff and clinicians should follow organisational protocols if high risk of suicide is identified; however Table 1 outlines potential responses to levels of risk. Table 1. Risk levels and response to suicidality. Level of risk Action No or minimal risk • Monitor as required. •
Low risk: some thoughts but minimal risk factors, no previous attempts, no specific plan, intention or means, evidence of minor self harm, protective factors (e.g., available supports). •
•
•
Moderate risk: thoughts, some risk factors, plan has some specific detail, means are available, intention to act in near future but not immediately, some protective factors (e.g., inconsistent supports) •
•
•
•
•
High risk: thoughts, previous attempts, risk factors, clear and detailed plan, immediate intent to act, means are available (and lethal), social isolation. •
•
Monitor closely and agree on a verbal or written contingency plan with client. Provide support numbers. Obtain commitment to follow the contingency plan should feelings escalate. Offer or refer for further assessment/contact with mental health or other appropriate service. Agree on a written contingency plan with client, clearly outlining relevant supports to be contacted if feelings escalate. Request permission to inform emergency monitoring team (CATT) and/or family. Consult with supervisor as necessary. Limit confidentiality. Immediately refer to hospital mental health services or emergency mental health team. Call ambulance/police if necessary. Obtain support from supervisor if required. Source: Lee, et.al., 2007. Section 3: Self reporting questionnaire (SRQ) The SRQ was developed by the World Health Organisation to screen for symptoms of the more common high prevalence mental health problems, such as anxiety and depression, among clients in primary care settings. There are 20 questions related to common symptoms of depression, anxiety and somatic complaints (such as sleep problems, headaches and digestive problems). The client is first asked to tick any symptoms that they have experienced in the past 30 days. For every ‘yes’ answer, the client is asked to tick whether they have experienced that problem when they were not using alcohol or other drugs. The clinician then counts the total number of ticks in the Page 26 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities circles and places the score at the bottom of the page. Scores should be interpreted on Section 3: Self Reporting Questionnaire of the PsyCheck as indicated in Table 2. The actions recommended are to be considered as an adjunct to usual practice. The PsyCheck Screening Tool is the basis of a stepped care model in which the treatment response is contingent upon the initial PsyCheck Screening Tool score. Table 2 outlines the incremental responses recommended and the PsyCheck Clinical Treatment Guidelines outline the specific intervention. PsyCheck screening materials, including a user’s guide with details of administration and scoring, are available through the Australian Government Department of Health and Ageing (www.health.gov.au). Table 2. Interpretation of the SRQ score Total score on SRQ Interpretation Action • Re‐screen using the PsyCheck 0* No symptoms of depression, Screening Tool after 4 weeks anxiety and/or somatic complaints if indicated by past mental indicated at this time health questions or other information 1‐4* Some symptoms of depression, • Offer Session 1 of the anxiety and/or somatic complaints PsyCheck Brief Intervention indicated at this time • Provide self‐help material • Re‐screen using the PsyCheck Screening Tool after 4 weeks • Offer Sessions 1–4 of the 5 or above* Considerable symptoms of PsyCheck Brief Intervention depression, anxiety and/or • Re‐screen using the PsyCheck somatic complaints indicated at Screening Tool at the this time conclusion of 4 sessions • If no improvement in scores evident after re‐screening, consider referral *Regardless of the client’s total score on the SRQ, consider referral if significant levels of distress are present. Source: Lee, et.al., 2007 Screening for psychosis Florid psychotic symptoms are usually easy to identify. However, methamphetamine users may present with a range of low grade psychotic symptoms that are unusual but more difficult to identify (Lee, et.al., 2007). These may include: • Paranoia: suspicions about treatment, friends or acquaintances, such as other people plotting to harm them. • Delusions: extreme beliefs that are unsupported by evidence, such as feeling invincible or a belief that someone is trying to contact them through the television. • Hallucinations: seeing, hearing, smelling or feeling things that other people cannot (Lee, et.al., 2007). Often methamphetamine users report tactile hallucinations, such as bugs or ants crawling under their skin. People may also report hearing voices or seeing things out of the corner of their eye. The most effective way of uncovering these symptoms is through the clinical interview. It is important © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 27 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities that the client feels comfortable enough to disclose symptoms. This is particularly important within the context of the TC, where the person may be interacting with many people, rather than a few clinicians or medical staff. The environment may therefore be overwhelming. It is therefore important that staff working with the client ask for information in a way that indicates that they understand the symptoms and reflect feelings back appropriately without reinforcing these symptoms (for example: 'that must make you feel scared') (Lee, et.al., 2007). The Psychosis Screener is an instrument which has been developed to measure psychotic symptoms. It may be useful as an adjunct to the clinical interview (see Work sheet 3: Psychosis screener). If you are unsure about how to assess for psychotic symptoms, consult with your local mental health service. Page 28 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Section 2: Tip Sheets © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 29 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 30 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 1: Dose effects of amphetamines Low dose Physical Psychological • Increases in systolic and diastolic blood pressure • Sweating • Palpitations • Chest pain • Shortness of breath • Headache • Tremor • Hot and cold flushes • Increases in body temperature • Reduced appetite • Euphoria • Elevated mood • Sense of wellbeing • Increased alertness and concentration • Reduced fatigue • Increased talkativeness • Improved physical performance High dose • High blood pressure • Rapid or abnormal heart action • Seizures • Cerebral haemorrhage • Jaw clenching and teeth‐
grinding • Nausea, vomiting • Confusion • Anxiety and agitation • Performance of repetitive motor activity • Impaired cognitive and motor performance • Aggressiveness, hostility and violent behaviour • Paranoia including paranoid hallucinations • Common delusions including being monitored with a hidden electrical device, and preoccupation with ‘bugs’ on the skin Effects of methamphetamine use Positive effects Negative effects
•
•
•
•
•
•
•
Euphoria Increased libido Alertness Diminished appetite Enhanced reflexes Feelings of confidence and physical strength •
•
•
•
•
•
•
•
•
Increased heart rate and irregular heart beat Abdominal pain Sweating Dilated pupils Fatigue Parasitosis (picking and scratching skin) Agitation, anxiety and paranoia Confusion, disorientation and hallucinations Psychosis Violent and aggressive behaviour © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 31 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 2: Managing acute toxicity While admissions to most TCs will occur after the detoxification period, some agencies also include withdrawal services as part of their overall service provision. These may be stand‐alone services, or part of a continuum of services whereby the person moves into the TC on conclusion of detoxification. Information gathered from the consultations also indicates some clients will present with symptoms after detoxification, and in some cases symptoms will emerge after admission to the TC. Recognising and responding to potentially toxic presentations can be challenging. The following information is outlined by Lee and colleagues (2007) in Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No 14: Methamphetamine dependence and treatment. Step 1: Observe clinical signs of toxicity As reaction to the amount of drug ingested will vary between individuals, clinical observation of toxic signs is more important than attempting to determine the amount ingested. Some individuals may experience these symptoms after relatively low doses of methamphetamine. Symptoms which may alert clinicians to potential toxicity include: • Chest pain • Rapid increase in body temperature • Psychotic features (such as hallucinations, paranoia or delusions) • Behavioural disturbances which may put the individual or others at risk • Seizures • Uncontrolled hypertension (Lee, et.al., 2007). Step 2: Monitor vital signs • Check temperature and pulse Step 3: Attempt verbal de‐escalation of the situation if required • Talk quietly and calmly to the person • Do not raise your voice or become agitated • Take the person to a quiet place where there are no distractions or potential weapons • If acute behavioural disturbance is a feature of toxicity, reliance on physical restraint is not recommended and may worsen the situation In some cases the client may need to be readmitted to hospital or withdrawal services for a period of time in order to stabilise or to manage withdrawal or mental health symptoms. Once the person is stable and medical, mental health and medication needs assessed and addressed, it is likely that they will be able to return to the TC to recommence treatment. Page 32 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 3: Managing aggressive or agitated behaviour Many TCs have noted that some methamphetamine and other ATS users will experience an increase in aggressive behaviour as a consequence of their methamphetamine and other ATS use. It is important for all staff and clients of the TC to be clear about the safety procedures and appropriate responses in managing clients who may, from time to time, present in an agitated or aggressive state. Discussion with all members of the TC, including staff and clients, is important in developing effective responses to these possible situations. Regular training, which includes role plays, can be invaluable in effectively responding and ensuring the safety of the client, staff and others in the vicinity (Lee, et.al., 2007). Behaviours associated with agitation that may become a concern include: • pacing • being unsettled • paranoia/suspiciousness • delusions (persecutory or grandiose) • argumentative with little or no provocation • easily upset over trivial things • threatening others • dissatisfied with everyone • offering unwarranted criticism • criticising surroundings • condemning staff of inadequate sensitivity, training or qualifications • claiming that everyone is out to make things difficult for them • feeling unsupported It is important to understand that the person’s judgement may be impaired and therefore their experience may not be the same as yours or others within the TC. Therefore, while it is important to maintain the overall essence of the TC in all clinical work, at times the way in which rules are implemented may need to be evaluated. When responding to difficult behaviours such as these, it is important to remain aware that this may be an indicator of the presence of psychotic behaviour that may make the person a risk to themselves or others. • Keep your voice low and controlled • Listen to the person • Avoid insincerity, ridicule or smiling • Avoid taking their behaviour personally • Explain to the person what is happening, what you are doing and why you are doing it • Avoid movements or actions which may be perceived as threatening, such as quick movements or moving towards the person suddenly • It is essential that you consider your own occupational health and safety at all times • Where possible, manage the physical environment so that you are able to leave if necessary • Make sure you advise others if you are about to enter a high‐risk situation • In the case of extreme agitation or aggression, the escalating threat of physical injury to the client, yourself or others will make it necessary to take more immediate action • Follow protocols appropriate to your organisation and request police or emergency service attendance if appropriate (Lee, et.al., 2007). © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 33 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 4: Some ffacts about C
Cravings (Adapted from Marlatt & Gordon, 1985 and Lee, et.al., 2007) 1. Cravings/urges to use are a natural part of modifying drug use. This means that you are no more likely to have any more difficulty in altering your speed use than anybody else does. Understanding cravings helps people to overcome them. 2. Cravings are the result of long‐term use and can continue long after quitting. So people with a history of heavier use will experience stronger urges. 3. Cravings can be triggered by people, places, things, feelings, situations or anything else that has been associated with using in the past. 4. Think of a craving in terms of a wave at the beach. Every wave/craving starts off small, and builds up to its highest point, and then it will break and flow away. Each individual craving rarely lasts beyond a few minutes. 5. Cravings will only lose their power if they are NOT strengthened (reinforced) by using. 6. Using occasionally will only serve to keep cravings alive. That is, cravings are like a stray cat – if you keep feeding it, it will keep coming back. 7. Each time a person does something rather than use in response to a craving, the craving will lose its power. The peak of the craving wave will become smaller, and the waves will be further apart. This process is known as extinction. 8. Abstinence is the best way to ensure the most rapid and complete extinction of cravings. 9. Cravings are most intense in the early parts of quitting/cutting down, but people may continue to experience cravings for the first few months and sometimes even years after quitting. 10. Each craving will not always be less intense than the previous one. Be aware that sometimes, particularly in response to stress and certain triggers, the peak can return to the maximum strength but will decline when the stress subsides. Taking this a bit further. Think of riding the waves as Urge surfing – going through the experience of craving without ‘fighting’ the experience. Focusing attention on the feelings and sensations and recording the intensity of cravings before and after the peak will help in gaining a sense of control over the experience. Page 34 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 5: Drug ttreatment metaphor (Adapted from Hermann Meyer, 2007) People get into drug use for all kinds of reasons. You can compare it to getting into boating. At first you are given free rides and you like it. Then you get your own boat and you enjoy your trips. But soon you find yourself adrift at sea attacked by pirates. You have to seek shelter in a shark infested archipelago, full of reefs, sandbanks, rocks and dangerous currents and things get really unpleasant and very scary. The sensible thing to do now is to throw in your anchor (which is a good metaphor for seeking help). You might do this to start off by going onto a pharmacotherapy program, doing some counselling, going into detox or doing some meetings. These are all good starts, and although you might still be in the same territory, for now you have steadied the boat and you are safe from running aground, drowning and being eaten by sharks. Remember, at this point there is nothing wrong with that sea anchor. You might want to pull it up and go on your way, but getting stabilised first is a good thing. You are not making any progress by setting yourself adrift again in those dangerous waters. In this situation the anchor is not your problem, it is your salvation. But over time you will want to move on. Maybe it’s getting too hard bobbing on the ocean, not really moving in any direction. So you think about where to go from here, looking for a safe direction and a worthwhile goal. Once you have made up your mind where you want to go, you plot a course out of the treacherous waters. Lifting the anchor free to move towards the goals you have chosen according to your deeply held values. Maybe it’s time to start to look at some of the reasons for your drug use? Maybe some of the other things that have been going on in your life could do with some attention? Makes sense? © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 35 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 6: Pavlov’s Dog Ivan Pavlov was a Russian scientist who was born in 1849 and died in 1936. His work was actually about understanding the way in which the digestive system worked. We all probably know the story. When a dog is given food, saliva starts to pour from the salivary glands in its mouth. This saliva is needed in order to make the food easier to swallow because it contains enzymes that break down the food. The same thing happens in humans. Pavlov became interested when he saw that the dogs drooled even when the food wasn’t around. Although no food was in sight, their saliva still dribbled. It turned out that the dogs were reacting to white lab coats. Every time the dogs were served food, the person who served the food was wearing a white lab coat. Therefore, the dogs reacted as if food was on its way whenever they saw a white lab coat. Pavlov then tried to figure out why this happened by doing a number of experiments. For example, he rang a bell when the dogs were fed. If the bell was sounded at the same time as the food was given to them, the dogs learnt to associate the sound of the bell with food. After a while, just at the sound of the bell, the dogs began drooling. After a while, Pavlov stopped giving the dogs food when the bell was rung. For a little while, they kept salivating. But then, even if the bell was rung, when no food followed, the dogs stopped salivating – this is called extinction. We call this process Conditioned Learning, and an important principle is that a response that we have been conditioned to, or taught, (salivating in the case of the dogs) becomes less intense if the stimulus (the bell in this situation) is repeated but without any reward (food). Nowadays, this knowledge has also been exploited by commercial advertising. What happens when you see a particular product advertised on TV or on a billboard? Seeing an image or just hearing the music starts us thinking – the Toohey’s music, ads that tell us that if we want to be attractive, or get the right girl or boy, we have to wear a particular product or look a particular way. The objective is to train people to make the ‘false’ connection between positive emotions (e.g., happiness or feeling attractive) and the particular brand of product. We also use this process to desensitise to particular things – like fear of spiders or fear of flying, by using techniques, such as muscle relaxation and imagining the fear‐producing situation while trying to reduce the person’s anxiety by relaxation. Now think about it from your own perspective. Conditioning forms the basis of many things which you have learned over the years – both positive and negative. What are some of the things you can associate with this process? What happens when you hear certain songs, advertisements coming on the TV, the sound of the dinner bell or someone announcing a group is being called? What are the feelings associated with this and where do you experience them? When you were using, what happened when you went to certain places, met up with certain
Page 36 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities people? Even if you had made a commitment not to use, going to places that triggered old behaviours meant that you sometimes fell right back into them. So one of the things you can do is not go to those places, not turn on the TV or listen to music that
might trigger thoughts again. Or you can change your response by starting to change the reward system. This might mean still going to the city or places which used to trigger thoughts of using, but this time change the reward system by going to a meeting or catching up with clean friends for a coffee. So gradually, even though the trigger is still there, you change the reward system. Over time, when you think of these places, hear the music, see people, you will have a different reward system that has become part of your life. You can change the way you react to things and the way you live your life. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 37 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 7: The Bridge Concept (Adapted from the Ley Community, UK) This concept illustrates how it is possible for people to overcome their problems and to get back into the mainstream of society by addressing their issues and substance use. Remember the way you were when you were on the scene; you'll probably have belonged to one of the groups on the left of the picture. If you were involved in drugs then you obviously knew a lot of people on the drug scene. And the same with crime, you probably knew a lot of scams, especially if you ended up in gaol. Well, the members of these groups had one thing in common, they knew how to relate to each other because they were part of the same scene. However, it’s possibly true that most of the contact they had was negative and they may never really have known how to relate on a meaningful level. Detox, starting to feel a bit better Into the program, not sure about it –
but I’ll give it a go. I’m ‘stepping‘ my way through, getting more supports and moving from one phase to the next. Halfway House and
Aftercare Program – Back into work or study My new life ‐
Family, friends, work, study and involved as a member of the community Before starting treatment ‐ other drug users, offenders, the ‘scene’ Maybe you wondered why you felt different to other people. Why you had to take drugs or alcohol, why you gambled and couldn't stop. Why you couldn't keep out of gaol for very long. Why you couldn't just be like everybody else, like the people on the other side of the bridge. Well, until you reached here you may never really have found out the answers although you probably tried many times. Maybe there was no‐one around to really help you? If you can imagine that there is a bridge in between the groups walking one way on the left, and the others on the right walking in the opposite direction, then ask yourself this question, "How many times have I tried to cross the bridge, get a job and get myself together?" Page 38 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities The answer is that you probably tried many times. Remember the times when you tried various 'cures'. Or saying to yourself in gaol that you're never going to get into any trouble again. Or just trying to go straight for the sake of it, or maybe even for a girlfriend/boyfriend or family. Whatever it was, sometimes when you tried to get yourself back on your feet again it was OK for a bit, but then it failed. Maybe it worked for a while, and that’s OK, because maybe you were able to make some changes, look after your health, change some of the ways you used, so that you didn’t do as much harm to yourself or those around you. Maybe you felt there was still something missing, but you didn't really know what it was, especially if you kept ending up in trouble, or your life just kept spiralling down. And so now you are here in this program. We are like a bridge, a bridge back to life ‐ hence the name ‐ Bridge Concept. You’ve made a start – got through detox and now you are in the first stage of treatment. Going over the bridge is a bit like stepped‐care, so you ‘step’ your way through it – there are different phases and different things you will do and learn along the way. As you go through this program you will learn things about yourself, make new friendships and gain new skills. At the end of this you will probably move into a halfway house or aftercare program and start work or go back to study – these are some of the things you will decide as you set your goals. The important thing is that you are on the bridge and one day when you look back on it, you’ll realise – “I crossed the Bridge!” © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 39 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 8: Managing your Feelings in Recovery The National Institute on Drug Abuse (NIDA) has identified the following eight steps to help understand and manage feelings to reduce the chance of using cocaine or other substances. These steps are useful for everyone, regardless of the specific feeling that they are dealing with or the substances which have been used. These steps equally apply to ATS use. Step 1: Recognise and label your feelings. Don’t deny your feelings because doing so can cause you difficulty in the long run. Even if you feel what you believe is a negative or bad feeling, remember that it is simply an honest feeling. Feeling an emotion doesn’t mean you have to act on it. You can also look for patterns in regard to your feelings. Do you tend to experience certain feelings much more frequently than others? For example, are you prone to feeling anxious and worried when things aren’t going your way, or when you have to go to certain places or see certain people? Step 2: Be aware of how your feelings show. Pay attention to how your feelings are reflected in your body language, physical changes, thoughts, and behaviour. These are clues you can use to become more aware of your feelings. For example, pacing and feeling “keyed up” or “tight” may indicate that one person is angry. For another person, this behaviour may indicate feeling worried. A person may be prone to headaches or other physical complaints when upset and angry. These or other physical cues may be signs that something is going on that needs your attention. When feeling upset, rejected, or frustrated, one person may be prone to going on mini‐shopping sprees. Another may turn to food and eat too much. Another person may withdraw and avoid other people when he or she is upset. The ways in which feelings are expressed through behaviour are endless. Your behaviours can also tell you something important about your feelings. Step 3: Look for causes of your feelings. Feelings aren’t usually caused by other people or events, but by how you think about them. Your beliefs about feelings play a big role in how you deal with them. For example, if you believe anger is bad and should not be expressed, you are likely to deny angry feelings or keep them to yourself. To understand why you feel the way you do, look at the connections among what you believe or think, how you feel, and how you act. Any of these components can affect another. Step 4: Evaluate the effects your feelings and your coping style have on both yourself and other people. How is your physical or mental health affected by your feelings? How is your behaviour, relationships with others, or self‐esteem affected? If your emotions or the ways in which you cope with them cause you distress or problems in your relationships with others, you need to work on changing how you deal with the feelings. You need to consider how your emotional states and your related behaviour affect others as well as yourself. For example, if you are depressed or angry, how does this affect your family? If you get irritated and snap at others when you are depressed, how does this affect them? Page 40 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Your emotions and the way in which you cope with them may have many positive effects. Most likely, some feelings have, more or less, a positive effect on your life, and some have more of a negative effect on your life. If a feeling or how you deal with it causes problems for you, this is a signal that you should consider making some type of change. Step 5: Identify coping strategies to deal with your feelings. Continue to use old coping methods if they are effective. However, you can learn new coping methods, if needed. There is no right way to cope with your feelings. How you cope depends on the specific situation you are in. Having a variety of coping strategies puts you in a good position to effectively deal with your feelings without using alcohol or other drugs. Step 6: Rehearse or practice new coping strategies. Practicing the way in which you might deal with a feeling, especially when another person is involved, can make you feel more prepared and confident about what you will say. Learning to express feelings appropriately is a skill that has to be learned and practiced just like any other skill. Sometimes you can practice by yourself by thinking of different things that you can say in certain situations. You can even practice how you might deal with your feelings toward another person in a given situation by rehearsing what you could say out loud. You also can practice with another person. For example, if you feel very attracted to a person with whom you work and want to ask this person out on a date but feel uncomfortable doing so, you can practice with a friend or family member. If you are upset and angry with a family member, work with someone else to practice different ways of sharing your feelings directly. Step 7: Put your new coping strategies into action. You can come up with a plan to deal with feelings, but if you don’t put your plan into action, it does little good. Action is needed for change. You have to translate your desire or need to change, into a behaviour. Don’t worry about making a mistake as this is to be expected when you first change how you cope with your feelings. Step 8: Change your coping strategies based on your evaluation of whether these strategies were effective. All strategies will not work the same in all situations. The key is having several coping strategies to rely on so that you don’t use the same strategy all of the time. Even if a coping strategy works well in one situation, it may not work in another. Make sure you have several strategies to help you cope with your feelings. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 41 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 9: The Fight or Flight Response
The ‘fight or flight response’ is our body's primitive, automatic, inborn response that prepares the body to ‘fight’ or ‘flee’ from perceived attack, harm or threat to our survival. What happens to us when we are under excessive stress? When we experience excessive stress—whether from internal worry or external circumstance—a bodily reaction is triggered, called the ‘fight or flight’ response. This response is hard‐wired into our brains and represents a genetic wisdom designed to protect us from bodily harm. This response actually corresponds to an area of our brain called the hypothalamus, which—when stimulated—initiates a sequence of nerve cell firing and chemical release that prepares our body for running or fighting. When our fight or flight system is activated, we tend to perceive everything in our environment as a possible threat to our survival. By its very nature, the fight or flight system bypasses our rational mind—where our more well thought‐out beliefs exist—and moves us into ‘attack’ mode. This state of alert causes us to perceive almost everything in our world as a possible threat to our survival. As such, we tend to see everyone and everything as a possible enemy. We may overreact to the slightest comment. Our fear is exaggerated. Our thinking is distorted. We see everything through the filter of possible danger. We narrow our focus to those things that can harm us. Fear becomes the lens through which we see the world. What is our fight or flight system designed to protect us from? Our fight or flight response is designed to protect us from the proverbial sabre tooth tigers that once lurked in the woods and fields around us, threatening our physical survival. At times when our actual physical survival is threatened, there is no greater response to have on our side. When activated, the fight or flight response causes a surge of adrenaline and other stress hormones to pump through our body. When we face very real dangers to our physical survival, the fight or flight response is invaluable. Today, however, most of the sabre tooth tigers we encounter are not a threat to our physical survival. Today’s sabre tooth tigers consist of rush hour traffic, missing a deadline or having an argument with our boss or partner. Nonetheless, these modern day sabre tooth tigers trigger the activation of our fight or flight system as if our physical survival was threatened. On a daily basis, toxic stress hormones flow into our bodies for events that pose no real threat to our physical survival. In most cases today, once our fight or flight response is activated, we cannot flee. We cannot fight. We cannot physically run from our perceived threats. When we are faced with modern day, sabre tooth tigers, we have to sit and ‘control ourselves.’ We have to sit in traffic and ‘deal with it.’ However, many of the major stresses today trigger the full activation of our fight or flight response, causing us to become aggressive, hypervigilant and over‐reactive. This aggressiveness, over‐
reactivity and hypervigilance cause us to act or respond in ways that are actually counter‐productive to our survival. This leads to a difficult situation in which our automatic, predictable and unconscious fight or flight response causes behaviour that can actually be self‐defeating and work against our emotional, psychological and spiritual survival. To protect ourselves today, we must consciously pay attention to the signals of fight or flight To protect ourselves in a world of psychological—rather than physical—danger, we must consciously pay attention to unique signals telling us whether we are actually in fight or flight. Some of us may Page 42 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities experience these signals as physical symptoms like tension in our muscles, headache, upset stomach, racing heartbeat, deep sighing or shallow breathing. Others may experience them as emotional or psychological symptoms such as anxiety, poor concentration, depression, hopelessness, frustration, anger, sadness or fear. Excess stress does not always show up as the ‘feeling’ of being stressed. Many stresses go directly into our physical body and may only be recognised by the physical symptoms we manifest. What can we do to reduce our stress and turn down the activity of our fight or flight response? The fight or flight response represents a genetically hard‐wired early warning system—designed to alert us to external environmental threats that pose a danger to our physical survival. Because survival is the supreme goal, the system is highly sensitive, set to register extremely minute levels of potential danger. As such, the fight or flight response not only warns us of real external danger but also of the mere perception of danger. This understanding gives us two powerful tools for reducing our stress. They are: i.
Changing our external environment (our ‘reality’). This includes any action we take that helps make the environment we live in safer. Physical safety means getting out of toxic, noisy or hostile environments. Emotional safety means surrounding ourselves with friends and people who genuinely care for us, learning better communication skills, time management skills, getting out of toxic jobs and hurtful relationships. Spiritual safety means creating a life surrounded with a sense of purpose, a relationship with a higher power and a resolve to release deeply held feelings of shame, worthlessness and excessive guilt. ii.
Changing our perceptions of reality. This includes any technique whereby we seek to change our mental perspectives, our attitudes, our beliefs and our emotional reactions to the events that happen to us. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 43 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 10: Coping With Anxiety: Bodily Symptoms Light headedness Tiredness Difficulty in sleeping Headaches Mind racing Sweating Dry mouth Tension Blurry vision Difficulty in swallowing Choking sensation Feeling breathless Breathing fast or shallow Sweating or shivering Heart racing Palpitations Chest pains Jelly‐like legs Shaking Trembling Restless Pins & Needles Wanting to run Stomach pains Nausea Lack of appetite or craving for food Butterflies in the tummy Bladder weakness Diarrhoea Page 44 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 11: (Changing) The Anxiety Cycle Intervention: Re‐evaluate, “It didn’t go well this time, I can change that”. Practice anxiety‐reduction techniques, positive self‐talk. Restructuring of thoughts & beliefs to change pattern Long held beliefs about being no Long held beliefs about being no good in social situations, “I’m a poor good in different situations, mixer”, “I just can’t talk to people”. “I’m a poor mixer”, “I just can’t talk to people”.
After the event: Catastrophic interpretations Avoid situations, “I can’t make it”. Before the event: Internal, external, symbolic & unconscious TRIGGERS Negative thoughts, “I looked stupid, I didn’t cope”. “Am I going to get into trouble, Will I get a complaint?” Negative automatic thoughts, “I’m not going to cope”. “How am i going to deal with this when I get there?” Social Anxiety Safety behaviours – e.g., avoids eye contact, keeps busy, sits away from others Intervention: Breathing Grounding Self‐soothing talk to change pattern and help cope with feelings of anxiety “I’m OK” Strengthen negative beliefs Physical symptoms – tense, heart palpitations etc During the event Focus on self, “I’m looking stupid”, “I’m sweating”. “Does it look OK, did I do it right?” Increased physical symptoms – sweating, tense © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Intervention: Breathing Grounding Self‐soothing talk to change pattern and help cope with feelings of anxiety “I can do this” Page 45 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 12: Ten Most Common Relapse Dangers & High‐Risk Situations 1. Being in the presence of drugs, drug users, or places where you used to “score” drugs or use. 2. Negative feelings, particularly anger, sadness, depression, loneliness, guilt, fear and anxiety. 3. Positive feelings that make you want to celebrate. 4. Boredom. 5. Getting stoned on any drug, including alcohol. 6. Physical pain. 7. Listening to drug use stories and dwelling on using. 8. Suddenly having a lot of cash. 9. Using prescription drugs that affect you, even if you use them properly. 10. Believing that you are finally recovered, that none of the above situations nor anything else stimulates you to crave drugs and that, therefore, it’s safe for you to use occasionally. High‐risk situations are those that threaten your recovery or trigger a strong craving to use. These are situations that remind you of using or that cause you to feel like you want to use drugs because others pressure you to do so. Upsetting emotions, serious conflicts with people, and difficult life problems are other potential high risk factors that can increase your vulnerability to relapse. It is your ability to use your plan to cope with your high‐risk situations that ultimately determines whether you stay drug free. • An example of a high‐risk situation is going to a party where people are using. This might make you feel like you want to use too, especially if you used to enjoy these kinds of social functions. • Another example of a high‐risk situation is a family get‐together where alcohol and other drugs are available or at which stressful family interactions such as arguments occur. It is helpful to identify the particular situations that are likely to put you at risk for using before you actually face these situations. You can then develop a plan to avoid them, if possible, or deal with them so that you don’t use. Your plan may involve going to meetings, talking to your sponsor or a supportive friend, engaging in some physical activity, assertively refusing substance use offers, changing your social habits, or actively planning social activities in non‐
threatening environments. • Talking to others in recovery about their dangerous situations and how they cope with them can be useful. Their ideas may help you develop strategies that will help you deal with your own high‐risk situations. Page 46 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Section 3: Treatment Modules © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 47 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 48 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Treatment intervention This section has been developed after bringing together information from a number of sources. This includes adaptation of some materials from the brief intervention developed for methamphetamine users (Baker et al., 2003; Baker et al. 2004), information from the Methamphetamine Dependence and Treatment Practice Guidelines, developed by Dr Nicole Lee and colleagues (2007), and information and exercises from Acceptance and Commitment Therapy (ACT), developed by Dr Russ Harris; Motivational Interviewing with Groups, developed by Dr Chris Wagner and Mindfulness‐
Based Cognitive Therapy, developed and presented by Liana Taylor. Training in Acceptance Commitment Therapy with Russ Harris, Motivational Interviewing with Groups with Chris Wagner and Mindfulness‐Based Cognitive Therapy with Liana Taylor was undertaken by the principal author prior to the development of the Treatment Protocol. This training reinforced the belief that all TC staff and clinicians engaged in using any of these techniques should firstly undertake the necessary training before using the materials. This is particularly important when utilising Mindfulness techniques, since clients with mental health problems may be susceptible to re‐traumatisation. In the hands of the untrained, it is possible that some techniques will create further distress. The Brief Intervention developed by Dr Amanda Baker and colleagues (Baker et al., 2003; Baker et al. 2004), is based on motivational interviewing and cognitive behaviour therapy. Results of the trial of this intervention (Baker et al., 2004) suggested that two or four sessions are effective in increasing abstinence among regular methamphetamine users. The authors state the four‐session intervention should be offered with stepped care principles in mind. The treatment manual for this intervention may be downloaded from www.health.gov.au. The Treatment Protocol for use by staff & clinicians working with ATS clients of Therapeutic Communities is divided into seven modules which may be utilised flexibly in the pre‐treatment stage or in the first stage of treatment. It addresses issues of craving, building motivation to change and strengthening commitment. It recognises that although the client has made a commitment to enter treatment, their continuation within a treatment program may be influenced negatively by a number of factors, including removal from the drug scene and possible harm, relaxation of family and court pressure and, very importantly, the loss of coping mechanisms – i.e., the drug use which has previously assisted the person to cope with the things with which they are unable to cope. The following modules are provided as part of the treatment package. The first two modules are aimed at clients who are in the pre‐treatment or very early treatment stage, and address motivation for change and understanding and dealing with the cravings which may continue for some time in the initial program phase. Module 3 commences the CBT and ACT training. Depending on the point of introduction, the Treatment Protocol can be used with some flexibility. For example, the first two modules might be used with clients at pre‐treatment on an individual or group basis. Group work within the TC might commence with Module 1, but could also commence with Module 3 if the first two modules have already been presented at pre‐treatment. Similarly, the final module, Relapse Prevention, may form part of the complete protocol, or be left aside until post‐discharge or be used as the third module in an outpatient setting. Module 5: Learning how to deal with anxious Module 1: Building motivation for change Module 2: Understanding and coping with cravings thoughts and feelings Module 6: Understanding and acknowledging Module 3: How thoughts influence behaviour core beliefs and values Module 4: Understanding feelings: Mind/Body Module 7: Relapse Prevention connection © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 49 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Trial of Treatment Protocol: First Study As a result of the first trial of the Treatment Protocol with Mirikai in Queensland and Cyrenian House in Western Australia, some changes have been made to the materials and the presentation. The prime concern expressed by participants and facilitators was that there were too many materials provided for each session – therefore sessions were lengthening out. This was impacted on further where homework tasks were not completed in the time between sessions and were therefore undertaken and processed at the commencement of each session. Therefore some of the materials have been changed, the wording of the Pavlov’s Dog worksheet (Module 2) has been changed considerably and has become a Tip Sheet and other activities (e.g., The Raisin Exercise in Module 3) are provided as suggested activities, but may be replaced by others (e.g., the Floating Leaves on a Moving Stream exercise could replace The Raisin Exercise). The purpose of The Raisin Exercise had been to reduce stress by slowing participants down and to bring their awareness into the present – it is a Mindfulness exercise which can be useful in helping people who have become cut off from their senses to be more in touch. However, its use must be a judgement call for the group facilitator. Some people found it difficult to approach the exercise mindfully and therefore were not able to get the value from the task. Others rated the exercise as one of the things they most liked about the module. The way in which Tip Sheets are used is also up to the group facilitator and the program. Different facilitators used them differently in the trial, some providing the Tip Sheets with little explanation, while others read through and processed the information with participants. The value to participants of discussing and processing the information was evident in the evaluations. However, another approach is to use the Tip Sheets independently of the session in a Concept Group or other forum during the time between groups to reinforce the learning. As an example, The Bridge Concept (Module 2) has been used in its original form by many TCs since the 1970s. The version here has been adapted as the original version was specific to the program (e.g., The Ley Community in the UK). Therefore the points of progress related to that program’s stages. For TCs that conduct concept groups, The Bridge Concept and other metaphors contained in the Treatment Protocol are useful additions to materials. In the context of the Treatment Protocol, The Bridge Concept, Some facts about Cravings, Drug Treatment Metaphor and other Tip Sheets could be used in this way. This would reinforce the materials from the module and could become the ‘homework task’. Therefore at the end of each module, suggestions have been provided as to how materials might be used in the time between sessions – hence The Bridge Concept, Pavlov’s Dog or the Drug Treatment Metaphor might be used in a concept group between Modules 1 and 2 and then discussed in Module 2. One suggestion coming from the evaluation was to present all the information pertaining to the module within the unit material – i.e., Tip Sheets and Worksheets included into the module’s materials, rather than in separate sections within the training manual. While this may make the presentation of the modules somewhat easier, the concern was that this would in fact work against a flexible use of materials – e.g., the flexible use Tip Sheets in the TC and as information sheets for staff, family members and others to help them better understand some of the issues which their family member might be experiencing. However, the order of sections has changed, so that Clinical Assessment is now Section 1, Tip Sheets (which may be used independently of the Treatment Modules) are in Section 2 and Sections 3 (Treatment Modules) and 4 (Worksheets) remain the same. At the commencement of each module outline, there is a list of materials needed for that module. Facilitators do need to read through this list, to prepare for the group – including photocopying the Page 50 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheets and Worksheets necessary for the number of participants in the group, but it is hoped that the presentation of the manual in this current form will assist in this task. Finally, we are grateful to the participants and facilitators at Mirikai and Cyrenian House for trialling the Treatment Protocol and providing such valuable feedback. We are delighted that the greatest concern was that there was too much information contained in the modules – that is a whole lot easier to address than finding the materials had completely missed the mark! Therefore, if it seems appropriate to break the module into smaller sessions, the invitation to do so is there. Although we have termed the following materials a ‘Treatment Protocol’ TCs, other treatment agencies and facilitators are invited to use the materials flexibly in a way that best suits their own client needs. The Treatment Protocol will continue to be assessed and evaluated. We look forward to your continuing feedback. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 51 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 52 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Module 1. Aim: To build motivation for change. Materials needed for Module 1: •
•
•
Worksheet 4: Lifestyle issues causing problems in my life Worksheet 5: Decisional balance – the pros and cons of continued ATS use Writing materials – it is suggested that folders be developed for clients, in which they can keep all materials, including the personal writing undertaken as part of this treatment intervention, along with Tip Sheets, Worksheets, homework and other resource materials. The folder should be brought to every session. Key elements of Module 1. Distribute Worksheet 4: Lifestyle issues causing problems in my life to help the client to articulate some of the problems caused by their ATS and other drug use. Step 2 – Reviewing motivating factors Invite the client to share one thing from the list which is considered a major motivating factor for change. If this is being undertaken in a group setting, each person can be asked to pair with one other person to share this. This should be done with due consideration to the person’s time within the program, their relationships with others and the amount of trust they have developed. Ask for feedback to the larger group – ‘Does anyone feel like sharing something about yourself from that last exercise?’ Discuss. Step 3 – The decisional balance Distribute Worksheet 5: Decisional balance – the pros and cons of continued ATS use and explain this to the client or group. • The decisional balance is used to help us think through what are the good things and the not so good things about continuing to use – and in particular the things that became associated with the use of drugs. • It also looks at the good and the not so good, or the difficult things about changing. If this is undertaken in a group format, it can be done on the whiteboard with everyone contributing. Each person should then fill in the sheet with information applicable to them. Step 1 – Building motivation to change These factors were nominated by ATS users in New Zealand as key lifestyle issues in relation to their continued ATS use. • Argued with others • Lost my temper • Had reduced work/study performance • Did something under the influence of drugs that I later regretted • Took sick leave/did not attend classes • Couldn’t remember what happened the night before • Damaged some of my own property • Had unprotected sex • No money left for any luxuries • Passed out • Upset a family relationship • I stole property • No money for food or rent • Damaged a friendship • Got into debt/owing money • Ended a personal relationship • Got arrested • Physically hurt someone else • Got a traffic ticket • Spent some nights sleeping rough (i.e., living on the streets) • Sacked/lost business/quit study course • Had a car crash • Had sex and later regretted it • Charged with a driving offence • Was kicked out of where I was living • Physically hurt myself • Overdosed on drugs • Was sexually harassed • Was sexually assaulted © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 53 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Step 4 – Assessing the decisional balance If this is being conducted on an individual basis, go through the exercise with the client, asking the person what were the good and not so good things about using; and then what do they think will be the good and less good things about stopping. Ask what is the importance of each factor. For instance, the client may have fewer reasons for stopping than continuing, but the weighting on each of these may be far higher than the weighting on the reasons for continuing. Establish whether the positive reasons outweigh the negative in terms of the number of issues listed for and against change, as well as the importance ratings attached to each of the factors. Step 5 – Strengthening commitment There may be resistance during this phase. Miller and Rollnick (1991) identified four categories of resistance behaviour in clients: 1. Arguing about the accuracy, expertise or even the integrity of the therapist or clinician. Therefore the person may be challenging, discounting or even hostile. 2. Interrupting in a defensive manner. This may mean that the person talks over others, or cuts them off when they are speaking. 3. Blaming, disagreeing or denying any problems. There is an unwillingness to recognise problems or to take responsibility. 4. Ignoring or not following the worker or clinician. In response to this, Miller, Zweben, DiClemente and Rychtarik (1995: 24) suggest: • Reflection – simply reflect what the client is saying; • Reflection with amplification – reflect, but exaggerate what the client is saying to the point where the client is likely to reject it. (But beware, don’t overdo it, or the person may become hostile). • Double‐sided reflection – reflect a resistant statement back with the other side (based on previous statements made in the session). • Shift focus – shift attention away to another issue. • Roll with resistance – don’t oppose – gentle paradoxical statements will often bring the person back to a balanced perspective. Step 6 – Explore concerns “You’ve said there are less good things about using speed or ICE – do these things concern you?” Explore health risks – “What do you think the effects on your health might be with continued use?” “Some people think giving up methamphetamine, ICE, speed etc can improve their depression. What do you think?” Other factors important to the person may be financial costs, losing contact with family – especially a partner and children. This can be undertaken in a group format – either in a full group if there are 10 or less members, or in pairs. Step 7 – looking back, looking forward “What was it like before you started using?” “How different would you like things to be in the future?” “What are your hopes for the future?” Help to develop discrepancy – “If I was to ask your mum, best friend, partner, what were your best qualities, what would they say?” “How would you describe the things you like about yourself?” Step 8 – if the person is ambivalent, explore the reasons for this and re‐establish the reasons for coming into treatment. Incorporate the information on health and psychological effects of continued use. Take clients back to their concerns on the Lifestyle questionnaire and decisional balance. Ask the person or group, “What happens as we put distance between ourselves and the things we saw as problems?” The answer – they don’t seem so bad! Page 54 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Motivation for change has historically been regarded as a prerequisite for responsiveness and readiness for treatment (Miller & Tonigan, 1996). Motivated clients are considered to be interested in changing and able to identify realistic goals. They may have an understanding of the basis of their symptoms and view therapy as an opportunity for self‐exploration (Rosenbaum & Horowitz, 1983). Conversely, lack of motivation for change has been seen as a result of defence mechanisms, such as denial, which pose obstacles to treatment and rehabilitation. An alternate view considers motivation to be a fluctuating state of balance between the pros and cons of a behaviour where motivational states may be influenced by a variety of factors in the social environment (Miller, Benefield, & Tonigan, 1993). Clients may be reluctant to change the antisocial behaviours that define them. They may lack self‐reflection skills and externalise problems by acting out or abusing substances. They may also be suspicious and distrustful of those in authority who attempt to help, especially where treatment is mandated (Eliany, 1992). Research on TC populations has shown that, generally speaking, clients entering a TC have reached the Action stage (Magor‐Blatch & Rickwood, 1999). However, if we consider motivation as a fluctuating stage, influenced by both internal and external factors, we are also able to understand that a person may move from the Action Stage back to the Contemplation or even Precontemplation Stage in response to both internal and external factors. Initiation of substance use Cessation of substance use Precontemplation Precontemplation
Contemplation Contemplation Preparation Preparation Action Action Maintenance Maintenance
Relapse Figure 1. Stages of change for initiation and cessation of (harmful) substance use Step 9 ‐ The Process of Recovery The group or client has now identified some specific effects of their drug use on themselves, possibly their families or significant others. • Define recovery from drug use as a long‐term process of stopping the use + change. • Identify the various components of recovery: physical, emotional, family, social, and spiritual. • Define denial as one of the key psychological issues to deal with in recovery, and identify ways to work through it. Methods/Points for Group Discussion Use discussion format to elicit and review the clients’ answers and record responses on the whiteboard. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 55 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Ask the group or client – “When you think of Recovery what do you think the different aspects of this might be? For example, we might think of Physical Recovery and Emotional Recovery. What other areas of our lives are important in the recovery process?” Write the following aspects on the whiteboard: • Physical Recovery • Emotional Recovery • Social Recovery • Family Recovery • Spiritual Recovery There may be others that clients may suggest. If so, put these up as well. Recovery involves making changes in oneself (internal change) and one’s lifestyle (external change). Improving or developing new coping skills is essential for change to occur. • Physical recovery involves good nutrition, exercise, getting adequate sleep, relaxation, and taking care of medical or dental problems. • Emotional recovery involves learning to cope with feelings, problems, stress, and negative thinking without relying on ATS or other drug use. • Social recovery involves developing relationships with sober people, learning to resist pressures from others to use, and developing healthy social and leisure interests to occupy time. • Family recovery involves examining the affects of drug dependency on one’s family, involving the family in recovery, and making amends. • Spiritual recovery involves learning to rely on a higher power for help and strength, developing a sense of purpose and meaning in life, and taking other steps to improve one’s ‘inner life’. Step 10 ‐ Define denial and ask clients to give examples of their own use of denial. State that a key early recovery challenge is breaking through ‘denial’ of dependency and motivating oneself to work on an ongoing program of change. Recovery is best viewed as a ‘we’ process in which the person uses the support of others, especially other individuals who are now sober and no longer use alcohol and other drugs. Goals need to be concrete, measurable, and Step 11 – The next step is to consolidate the realistically achievable. Clients in the issues raised by the client, and to build on their Preparation and Action Stage may need practical motivation for change. Shift the focus to negotiating a plan for change. The final task will assistance with approaching goals in manageable be to help the client determine an initial goal. steps. These may be modelled through problem‐
This is a short term goal which they will be able solving strategies to assist clients with working through practical issues with goal selection and to achieve by the next session. Set just one. attainment. Explore any fears through problem solving for each fear raised. Talk through the characteristics Continued use of motivational interviewing of goal setting ‐ pointing out that goals can help strategies, particularly supporting self‐efficacy, regardless of whether or not they are achieved. are important to maintain commitment. Page 56 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities There are a number of Tip Sheets which form part of the next module. These are: • Tip Sheet 4: Some facts about Cravings • Tip Sheet 5: Drug Treatment Metaphor • Tip Sheet 6: Pavlov’s Dog • Tip Sheet 7: The Bridge Concept As a prelude to Module 2, Tip Sheet 5: Drug Treatment Metaphor, Tip Sheet 6: Pavlov’s Dog and Tip Sheet 7: The Bridge Concept, could be used in a Concept or Education Group to set the scene and reinforce the learning which will be gained in the next module. In particular, The Bridge Concept has been used by many TCs over the years, and adapted to their own individual program. The adaptation here can be applied to all programs, and as with all materials it is important that clients apply the information to their own lives. This is the prime value of concepts and metaphors in the treatment setting. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 57 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 58 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Module 2. Aim: To learn how to understand and cope with cravings. Materials needed for Module 2: •
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Tip Sheet 4: Some facts about Cravings Tip Sheet 5: Drug Treatment Metaphor Tip Sheet 6: Pavlov’s Dog Tip Sheet 7: The Bridge Concept Worksheet 6: Vitality vs. Suffering Worksheet Worksheet 7: Vitality vs. Suffering Diary Key elements of Module 2. smell of substances or people, places, events, or experiences related to substance use (e.g., drug dealer, friends who use, places where using occurred, music associated with getting stoned, etc.). Cravings also are triggered by internal factors, such as obsessions or thoughts about using drugs, or mood states such as anxiety, boredom, or depression. Cravings to use are temporary and will pass in time. The client needs to use coping strategies to resist giving in to a craving. The first step in normalising cravings is understanding the variety of situational, social and psychological triggers which have been associated with use (Lee, et.al., 2007). This is essentially a Classical Conditioning model. Ask about Pavlov’s dog? Does anyone know this story? Give out Tip Sheet 6: Pavlov’s Dog. Ask each person to give an example of a situation in which they can identify this phenomenon. It might be lunch being called, or a group being announced. What are the feelings and where do they experience them? For example, fear may be felt in the stomach, excitement in the chest. Do they get anxious, what happens? Does their heart start racing, palms get sweaty? These are normal reactions. What have they done in the past when these feelings have been experienced? Encouraging clients to tolerate conditioned cravings is also facilitated by stressing the time‐
limited nature of cravings. For most people, cravings peak and dissipate within an hour. Step 1 – Review last session. Ask client(s) to take out their goal from last session. Were they able to achieve it? What were the things that helped them achieve the goal – and what were the barriers that made it difficult? How did they overcome them? Was there a point when they thought they would not be able to achieve the goal? Ask the client(s) to write down what the problem was, what their thoughts were or ask each person to state the issues or concerns and write them on the whiteboard. Step 2 – Understanding and coping with cravings. This is frequently cited as one of the most difficult problems for ATS, and especially methamphetamine users, to deal with (Lee, et.al., 2007). Cravings can last weeks and even months, causing issues for clients in the early stages of the TC. This is the point where there is greatest attrition, so it is important that clients gain an understanding of the reasons and the triggers for cravings and learn to normalise the experience and to develop skills to manage the cravings when they occur. Handout: Tip Sheet 4 – Some facts about cravings Step 3 ‐ Understanding cravings. Craving refers to an impulsive, spontaneous urge to use ATS, methamphetamine or other substances. A craving may include strong thoughts of using drugs, physical symptoms such as heart palpitations and sweating, or behaviours such as pacing. Cravings are triggered by many external stimuli in the environment, such as the sight or © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 59 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Clients may experience direct and indirect social pressures during recovery. These pressures can lead to relapse if the person is not prepared to handle them and refuse offers of alcohol or other drugs. Part of this process, is assisting clients to ‘recognise, avoid and cope’ (Lee, et.al., 2007). While there is safety in the TC and therefore avoidance of some situations will be relatively non‐problematic, avoidance in itself is not without risks. Simply avoiding all social contact and activity is counter‐productive. A problem solving approach to working around triggers and cues to drug use is helpful, particularly if there can be some collaborative ‘reality testing’ of the workability of each strategy. For many clients who are entering treatment in their ‘home town’ attending support meetings (NA and AA for example) in locations where using took place can be described as changing the cues to using. So instead of scoring, you go to a meeting, have a coffee with ‘clean’ friends afterwards – and in doing this you start to change the cues (‘this is where I score’), to the trigger (the location) and have a different outcome (meeting and coffee instead of using). Without further use, the mechanism of extinction will lead to the weakening of the conditioned craving response over time (Lee, et.al., 2007). Step 4 – It is possible to fit the person’s experience of cravings into the following model: Behaviours + Physical + Thoughts = Cravings. It is important to use coping techniques that address each of these elements in order to cope with cravings (Baker, et.al., 2003). Identifying triggers. Understanding triggers is a very important part of this process. Triggers refer to experiences, people, situations, events, or things (objects) that stimulate a desire or craving to use drugs or other substances. A trigger can lead to a relapse if the person doesn’t have coping strategies to manage the craving. Therefore, part of changing drug using behaviour is also about changing the places and the friendships associated with drug use. What have been some of the triggers to drug use in the past? Brainstorm these on the whiteboard. Begin to generate some ideas about how these situations could be coped with differently if you apply the ‘Pavlov’s Dog’ model – i.e., that extinction would follow if the reward didn’t arrive. Ask clients to give examples of social pressures and other triggers to use drugs or alcohol. After eliciting clients’ examples of triggers, review the common triggers listed below and add any to the list on the whiteboard that clients didn’t Identify: Step 5 ‐ Social Pressures and Triggers to Use Alcohol and other Drugs • Drug‐using friends or family members. • Dealers. • Events or celebrations where alcohol or drugs are present. • Music associated with partying or using substances. • Sex and sexual partners. • Drug paraphernalia. • Places where drugs were obtained. • Places where drugs were used. • Some jobs (particularly if people used drugs on the job). • Money or the anticipation of getting money. • Weekends or celebrations. Page 60 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities •
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Certain smells, even the smell of matches. Feeling lonely, sad, angry, bored, or depressed. Positive memories of using. Negative thoughts of recovery. Discuss how to avoid the triggers that members have identified as powerful. Ask the group members to identify strategies that they’ve used in the past or could use in the future to manage a drug craving or resist social pressures to use. Step 6 ‐ Behavioural Strategies Discuss the ‘3Ds’ of coping: 1. Delay the decision to use when a craving occurs: This means delaying the decision to act for a period of time – 1 minute, 2 minutes, 3 minutes as the person gains more confidence and mastery over their feelings. This will help break the habit of immediately reacting to a craving, and can be applied to other areas of concern in the person’s life. 2. Distract yourself from thoughts about using: Generate some ideas for strategies to use as a distraction technique. These should be written down and kept accessible by each person to use as a reference when things become difficult. This might include the following: • Talk to a peer, a staff member or call a friend or sponsor to discuss the craving. • Go to an AA, NA, or other support meeting. • Get some physical exercise. • Read, particularly about recovery. • Spend time with sober people. • Keep busy. • Undertake an activity. • Avoid high‐risk people, places, and events. 3. Decide not to use again by thinking through all the reasons for stopping in the first place: Congratulate yourself for not giving in and remind yourself – it’s only a THOUGHT or a FEELING (Baker, et.al., 2003). Step 7 ‐ Cognitive Strategies • Remember that cravings and desires for substances eventually go away. • Think positively and tell yourself you can fight off your craving. • Talk yourself through the craving. • Pray or ask for strength from your higher power. • Practice ahead of time how to refuse substance offers. Step 8 ‐ Relaxation and imagery Relaxation techniques and deep breathing are important techniques to learn and use in response to stressful situations. Using a relaxation CD will assist in developing skills which the person can then apply when they become stressed or anxious. Other skills, such as ‘urge surfing’ (refer to Tip Sheet 4) should be discussed and utilised to increase the person’s chance of successfully resisting cravings. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 61 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Acceptance and Commitment Therapy (ACT) (The following is meant as information for facilitators in preparing the session). Suffering is a basic fact of life for humans. However, suffering is not just about pain, psychological or otherwise. It's much more than that. We don’t just experience pain; we agonise over painful memories, uncomfortable emotions, difficult self‐evaluations, often ruminating over and over, even though the past cannot be changed. These memories and situations worry us, and we may engage in all kinds of activities to avoid them. People want the suffering in their lives to be minimised. For people who have pushed away these memories and feelings for a long time with the use of drugs, suffering has become a way of life, which is not even recognised as suffering. A good life is much more than simply a lack of suffering. We want to live well and make the best of our time on this earth. While Acceptance and Commitment Therapy (ACT) is about the problem of human suffering, it’s about much more than that. It’s about reaching beyond suffering to the larger purpose of people's lives and helping them get active in really living. ACT is centred on such questions as “What do you really want your life to be about?” or “If you lived in a world where you could have your life be about anything, what would it be?" (Harris, 2007). ACT is a cognitive‐behaviour therapy that has gained increasing attention in recent years. ACT emphasises such processes as mindfulness, acceptance, and values in helping clients overcome obstacles in their lives. A basic assumption of ACT is that suffering is a normal and unavoidable part of human experience and that it is actually people's attempts to control or avoid their own painful experiences that lead to much long‐term suffering. ACT helps people learn ways to let go of the struggle, be more mindful, get clarity on what really matters to them, and to commit to living full, vibrant lives. The goal of therapy is not to eliminate certain parts of one's experience of life, but rather to learn how to experience life more fully, without as much struggle, and with vitality and commitment (Harris, 2007). ACT uses exercises and metaphors to assist clients. Hand out the Tip Sheet 5: Drug Treatment Metaphor. Ask client(s) if they can think of ways in which they use metaphors to help them cope with or understand situations. These are often used in the TC as ‘concepts’. Hand out Tip Sheet 7: The Bridge Concept from the Tip Sheets section. This concept has been used by TCs for many years, and may have been adapted to individual programs. It gives a pictorial image of moving from where you have been, to where you might want to be in the future. Step 9 ‐ Vitality vs. Suffering The next exercise comes from Acceptance and Commitment Therapy (ACT) and was developed by Dr Russ Harris (2007). Hand out Worksheet 6: Vitality vs. Suffering Worksheet. Introduce this exercise by asking client(s) to think about the main thoughts and feelings that they struggle with – the ones that get them down, interfere with their lives, or set them up for a struggle with themselves or others. There are two circles which represent mind and body. In the body circle, they should write down whatever they struggle with that they can feel in their bodies, including the sensations, urges, cravings, (and sometimes symptoms of physical illness). In the mind circle, they should write down Page 62 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities whatever they struggle with in terms of thoughts, self‐judgments, memories, worries, fantasies – and any beliefs or ideas that seem to set them up for a struggle with their own lives, or with other people. Some things, such as fear or anger, may be experienced in both body and your mind – so they should be written in the area where the circles overlap (Harris, 2007). As they are writing, it is helpful to do some subtle defusion, by asking questions like: “When your mind seems to be really giving you a hard time, telling you what’s wrong with you or your life, what are some of the nastiest things it says to you?” Or if the client writes down a stream of negative self‐
judgments, you might say, “Your mind really likes to give you a hard time, doesn’t it? How long has it been telling you this sort of stuff? What’s the earliest you can remember it trying to tell you what was wrong with you?” (Harris, 2007). Once that part is completed, let people know that what they have written are the kinds of things they struggle with. It’s not a comprehensive list of every thought and feeling and memory that ever troubles them – but it gives a general overview. Now point out the top half of the sheet ‐ ‘Vitality’. Vitality is what we’re aiming for in this work: a sense of wellbeing, a sense of being fully alive. So on the top half, ask everyone to write down all the positive things they have ever done when these difficult thoughts and feelings showed up – i.e., things that that improved their lives, health, happiness and vitality in the long term. Sometimes it didn’t feel that way, it felt hard, but the long term benefit was positive. Having completed that part, draw attention to the bottom half of the sheet – ‘Suffering’. Suffering is what we’re aiming to reduce. Suffering means everything that they EVER do, when these painful thoughts and feelings show up, that makes their life worse. These are all the negative things that they’ve EVER done when these thoughts and feelings showed up – all the ways they wasted their time, energy, and money, or damaged their health, or hurt their relationships and the people they cared for, or otherwise worsened their lives in the long term (Harris, 2007). Once again, some things, like using, might have felt good in the short term, but the long term effects are what they are now dealing with. This is a powerful exercise, as we don’t often think about these issues in such strong terms – Vitality, Suffering. Step 10 – Homework. Worksheet 7: Vitality vs. Suffering Diary. This is to be done over the next week. Introduce it by saying you would like everyone to maintain a diary, to keep track of what’s happening in their lives and to help them to begin to understand the way in which they react to situations – especially as many of these will have become automatic coping mechanisms. The idea is to become aware throughout each day, of the difficult thoughts and feelings as they show up. Ask everyone to write down the thoughts and feelings in the first column. Then write down what they do in the other two columns. If what they do seems to improve their lives in the long term, if it makes them begin to feel that life is rich and full and worth living, and improves their health, vitality, and relationships, then write it in the vitality column. However, if what they do seems to worsen their lives in the long term, these things should be written in the suffering column. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 63 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Again, emphasise the words ‘LONG TERM’ here, because that’s what we’re interested in: the big picture. If they do something that makes them feel good in the short term, but negatively impacts on health, wellbeing, vitality, or relationships in the long term – then that should go into the suffering column. This will take five to ten minutes each day to fill in and should be done at a specified time. Ask each person to specify when they will elect to fill it in, e.g., immediately after lunch, or before they go to bed. Ask each person to do the first entry so that they understand how it works. Discuss this. As there are no Tip Sheets included in next module, it may be possible to check in with clients in the time before the next session to see how they are going with the homework. Doing homework is not necessarily part of the person’s thinking – so this may be somewhat difficult in the beginning. However, this is one activity which was found by participants in the trial to be very useful, therefore, if they are able to complete it, the Vitality vs. Suffering Diary will be helpful in understanding how we act and what the end result of those actions might be for each person. Page 64 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Module 3. Aim: To understand how thoughts influence behaviour. Materials needed for Module 3: •
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Worksheet 8: Unhelpful thinking patterns Worksheet 9: Self‐monitoring record Packet of raisins, with enough for the group, placed on a plate. The Raisin Exercise, however, is optional and might be replaced by another meditation or relaxation exercise. Therefore, both are provided here, but only one should be used with the group. Key elements of Module 3. Step 1 – Last week’s homework – The Vitality vs. Suffering Diary. What did each person gain from this? What did they notice, were there more Vitality or Suffering reactions? Point out that it is normal to be reacting in a way that increases suffering at the beginning, but that as they become more aware of their thoughts, feelings and emotions, they will also start to consider the way in which they react and the consequences of this. Step 2 – Reframing reactions. Ask each person to give an example of one way in which they reacted that increased their Suffering, rather than Vitality. List these on the whiteboard. Now ask the group for suggestions about the way in which these might be reframed – i.e., instead of acting in a way to increase suffering, what might the person have done to increase their vitality?
Step 3 – The Raisin Exercise (This exercise is optional and could be replaced with the Floating Leaves on a Moving Stream Exercise, provided below). This is a Mindfulness exercise that helps to do a few important things. Firstly, it slows us down, so it is often used as a stress reduction exercise, secondly, it helps us to become aware of our senses, and this is very important for people who have become cut off and are no longer in touch with feelings. Finally, we ask people to do this mindfully, i.e., to consider each step in this process, to be aware of what they are doing. Offer each person a raisin from a plate which you will pass around. Ask each one to pick up a raisin. Look at it. Really look at it ‐ like you've never seen a raisin before. Roll it between your fingers. What do you notice about its texture, its colour? If you were to put the raisin back onto the plate, would you be able to recognise it again? What are the particular things about this raisin that you notice? Give a few moments for this and each stage. Then ask each person to hold the raisin to their ear. You shouldn’t put it in your ear, you will be eating it later – so just hold it there. Squish it a bit. Does it make a sound? Now take it to your nose. How does it smell? Ask each person to close their eyes at this point, so they can really concentrate focus their awareness. Now ask each person to bring it to their lips. Ask them to take note of any stray thoughts they might have, but always come back to the raisin. Place it on your tongue. Just hold it there. What are you aware of now that you have it in your mouth? © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 65 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Then ask them to bite into it. Savour it. When you finally swallow it, appreciate the fullness of its flavour. Now ask each person to imagine that their bodies are exactly one raisin heavier. At the end of this exercise, ask for feedback. Some people will feel it’s a bit silly, but what was it like when they were attending, being aware and mindful about the task and about the raisin? Step 3 (Alternate exercise) – Floating Leaves on a Moving Stream Do this exercise for at least five minutes. Keep a watch or a clock and note when you start the exercise. This will be useful in answering some of the questions at the end of the exercise. This will be an eyes‐closed exercise. Imagine a beautiful slow‐moving stream. The water flows over rocks, around trees, descends down‐
hill, and travels through a valley. Once in a while, a big leaf drops into the stream and floats away down the river. Imagine you are sitting beside that stream on a warm sunny day, watching the leaves float by. Now become conscious of your thoughts. Each time a thought pops into your head, imagine that it is written on one of those leaves. If you think in words, put them on the leaf as words. If you think in images, put them on the leaf as an image. The goal is to stay beside the stream and allow the leaves on the stream to keep floating by. Don't try to make the stream go faster or slower; don't try to change what shows up on the leaves in any way. If the leaves disappear, or if you mentally go somewhere else, or if you find that you are in the stream or on a leaf, just stop and notice that this happened. File that knowledge away and once again return to the stream, watch a thought come into your mind, write it on a leaf, and let the leaf float away down the stream. Hayes, S. C. (2005). Get Out of Your Mind & Into Your Life. P. 77. New Harbinger Publications, Oakland CA. At the end of the exercise, ask the following questions: • How long did you go until you got caught by one of your thoughts? • If you got the stream flowing and then it stopped, or if you went somewhere else in your mind, what happened just before that occurred? • If you never got the mental image of the stream started, what you were thinking while it wasn't starting? Step 4 ‐ Link between thoughts and behaviour: the ABC model. It helps to explain the CBT model. Explain the CBT model by starting with the simple concept that the way in which we interpret situations determines how we feel and behave (Lee, et.al., 2007). Role play this with an older resident or another staff member. Write A, B, C on the whiteboard. Explain the A stands for Activating Event. This might be an actual event, or it might be a thought or a feeling that comes over the person. The B stands for Belief. These are the things we think and believe about ourselves and others in response to the situation. C stands for Consequences and these are usually the actions we take as a result of both A and B. It might be a behaviour or it might be the way that we feel as a result of what has happened. Mapping this out on the whiteboard, ask the person to give you an example of a situation to Page 66 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Step 5 ‐ Unhelpful thinking patterns. Ask the group what they were thinking as they listened to this scenario – could the person have got it wrong at the beginning, i.e., could there have been another reason why the first person didn’t answer? What if the first person didn’t hear the greeting, what if he or she was in their own space and it had nothing to do with the person who has now become affected by this? On the whiteboard, ask the group to generate as many different explanations for this event as they can think of. Record all of these. Many clients will have difficulty generating alternative ways to interpret the situation. You may need to prompt or brainstorm alternatives (Lee, et.al., 2007). Step 6 – Naming unhelpful thinking patterns. Distribute Worksheet 9: Unhelpful thinking patterns. Ask the group what were the unhelpful thinking patterns demonstrated by the last exercise. Write these on the whiteboard. Ask each person to pick out their 2 ‘favourite’ unhelpful thinking patterns from the Worksheet and see if they can give an example. This can also be done in pairs or small groups. What have been the consequences of these thinking styles? which they reacted recently. This might be something like, “When I got up this morning and came down to breakfast, one of my peers ignored me when I said hello”. (This goes in A). Ask the person what they were thinking when that happened. The person might respond, “I thought, well stuff you! Do you think you are better than me? It made me think I wasn’t good enough to talk to, like I was a piece of crap!” Put this in B. Point out this is also beginning to paint a picture of what the person believes about him/herself. Next ask what happened then? The person might say, “Well instead of sitting next to the person for breakfast I went and sat with someone else, even though I knew the person I sat with has got one foot out the door”. Ask some more questions – what happened next, and how do they feel now? The response might be, “I felt even worse, the person I sat next to was in a full‐on negative rave. It just brought up a whole lot of things. I got really angry and stormed out of the dining room. I still feel really upset, it’s brought up a whole lot of things about how I never seem to fit in.” This goes in C, but you can also add the bit about never fitting in, into the B column. Step 7 ‐ Self monitoring. Once a person has identified the unhelpful thought patterns that apply to them, it is important to learn ways to identify and challenge them. The main steps to changing unhelpful thought patterns is first to recognise it when it happens, to ‘catch yourself thinking in this way, recognise the thought pattern for what it is, and then substitute it with a more helpful or reasonable set of thoughts’ (Lee, et.al., 2007: 53). Breaking events down into situations, unhelpful thoughts, feelings and behaviours can take practice. It is important to ask each person to practice this skill in between sessions. By asking the client to ‘self‐monitor’, they will begin to gain new awareness about their thoughts and feelings and how they lead to behaviours, including alcohol and other drug use (Lee, et.al., 2007). Step 8 – Distribute Worksheet 9: Self‐monitoring record. This diary includes the A, B, C model which was practised at the beginning of the session, and also includes a column to write down the unhelpful thinking styles that may been used. Finally it introduces ‘D’ – Detective Work and Disputation. So if the person has recorded something in the previous column that points to a © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 67 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities particular type of thinking pattern, they have to ask, where’s the evidence that this is the case? This is the first ‘D’ – Detective Work. • It is common for people to mistake their feelings for evidence/fact – when in reality feelings are not facts. Often the evidence is contradictory to the person’s thoughts and feelings. • What are the advantages/disadvantages for thinking this way? The idea that someone can get a positive benefit from a negative thought might be challenging. Explore this. Sometimes it allows people to stay exactly where they are. They don’t need to change and they can go on behaving the way they have been. What would happen if they challenged some of these thinking patterns? • Is there a thinking error? Is the person falling into one of the unhelpful thinking styles? Ask clients to review the list and consider if they are falling into one of these patterns. The second part of ‘D’ is Disputation ‐ • What are the alternative ways of thinking about this situation? There will always be more than one way to interpret a trigger situation. Often these alternatives will be more helpful than the previous interpretations and consequences which result from unhelpful thinking styles. Brainstorm some alternative ways of thinking/reacting to stressful/trigger situations with the group. Filling out this worksheet is the homework task for this week. Page 68 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Module 4 Aim: To understand feelings and make the Mind/Body connection. Materials needed for Module 4: •
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Tip Sheet 8: Managing your Feelings in Recovery Worksheet 10: Understanding how we experience Feelings Worksheet 11: Feelings of Anger, Loss, Shame and Guilt Worksheet 12: Pleasant Events Calendar Coloured pencils or crayons Key elements of Module 4. Step 1 – Relaxation Exercise This relaxation exercise can be used to calm or soothe. Read the following script: “Let’s start by finding a position where you are comfortable. You can sit in your chair, or if you feel comfortable, find a place on the floor where you can lie down without bumping into anyone. Close your eyes, or if this doesn’t feel comfortable, leave them open and allow yourself to hold a soft focus on an object or the ground just a little way in front of you. Take a deep breath while you silently count to four: one...two...three...four. Now breathe out slowly, one...two...three...four. Try to breathe from your tummy, not just your chest. Breathe in again. And out again. Now, repeat that slow breathing two more times. Now, in your mind, I want you to picture your favourite safe place. Maybe you are in a park, by the beach, in a favourite chair. Maybe you are lying in the sun. Picture that place in your mind and imagine yourself there. Keep breathing deeply and very slowly. Starting with your head and working down your body like a scan, let your muscles relax. Let your forehead relax. Let your cheekbones relax. Let your jaw relax. Let your neck and upper shoulders relax. As you exhale, imagine all the tension going out with each breath. Let it go. Let your hands and arms go limp next to you. Let your chest, stomach, and whole middle part of your body relax. Keep breathing in and out. Let your hips, your buttocks, and your upper legs and lower legs relax. Let your feet and toes relax. Let your whole body relax. Breathe in and out. Keep imagining that safe place you selected. Enjoy where you are; enjoy the tension going out of your body. Be relaxed, almost floating and weightless, as you stay with that image. Now open your eyes. How do you feel right now? Do you feel more relaxed?” © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 69 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities and contain feelings is important so that feelings are no longer able to control us. The following five steps can help you begin to create emotional wellness in your life. Five steps to Emotional Wellness: 1. Become aware of when and how you are feeling. Tune in to yourself. 2. Try to locate the feeling in your body. Where are you experiencing the sensations? 3. Name the feeling – label it. 4. Express the feeling. 5. Learn to contain it. Distribute Tip Sheet 8: Managing your Feelings in Recovery. Discuss this. Step 2 – Review the homework task – The ABC Model. What were the key learnings from this task? What were the unhelpful thinking styles that each person found themselves slipping into? How were they able to change these patterns? Step 3 – Making the Mind/Body Connection. Many things can impact on our emotional development. Using substances will severely impact on emotional wellbeing and development, as will trauma. Often substance use is the way in which we cope with traumatic events. This may lead to ‘psychic numbing’ as we shut down emotionally to help cope with pain. This may mean that we have become unaccustomed to having feelings. If this has happened, it may be necessary to find the words to name these feelings. Learning to both express Step 4 – Distribute Worksheet 10: Understanding how we experience Feelings and coloured pencils or crayons. This worksheet provides a list of feelings, some of which will be familiar to members of the group. Ask each person to choose one of the feelings from the list and to mark on the diagram where in their body they experienced the feeling. They should choose an appropriate coloured pencil or crayon to describe the feeling. Use small groups, partners or the larger group to discuss this. What are the feelings that each person chose? Where are they felt in the body? What colour did each person choose to describe the feeling? Choose another feeling – this time choose one which is different to the first, and one you would like to feel more often. For example, if you chose ANGRY, then maybe you would like to feel HAPPY. Where would this new feeling be experienced and what colour would it be? Step 5 – Common feelings experienced by people who have used drugs include: ANGER, LOSS and SHAME. Sometimes when people feel ANGER, they turn it back on themselves, especially if they are unable to express it. This may result in feelings of depression. Some anger may become self‐harming behaviour, and in some cases the anger will cover other feelings like FEAR. Fear or sadness can sometimes be underneath anger. Using the whiteboard, ask the group to brainstorm the ways in which they have shown anger in the past. Then, making a second list, brainstorm some more healthy ways of expressing anger. How do they use the processes in the TC or in recovery to more effectively deal with feelings of anger? LOSS and GRIEF are common experiences for people who have abused drugs. Some people have multiple losses, children, partners, family members and/or friends. Even the loss of their childhood or youth and health will cause grief. Page 70 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Ask clients to think back over their lives. Using Worksheet 11: Feelings of Anger, Loss, Shame and Guilt, ask clients to think back over the losses they have experienced in their lives. They don’t need to talk about these, instead they should record on the worksheet the ways in which these losses have affected them. Did they use drugs to help cope with the losses? Where did this ultimately lead? Step 6 ‐ Shame is a painful belief in one’s basic defectiveness as a human being. Shame can involve feelings of humiliation, mortification, dishonour, or disgrace. Guilt refers to feeling bad about one’s behaviours, including things one did or failed to do. Examples of behaviours someone may feel guilty about include: • Saying or doing things to hurt family or friends. • Acting in a way that does not match your values. • Committing crimes. • Lying to and cheating others. • Conning family members or using family money to buy drugs. • Not acting responsibly as a parent or partner. • Failing to take care of personal responsibilities. Substance use invariably produces feelings of guilt and shame that damage the person’s self‐esteem. People who have used drugs usually experience feelings of guilt and shame over their behaviour while they were using, and they may feel ashamed for using, or for the things they did while using. This seems to be particularly true for ATS users. Some people may not feel worthy or deserving of recovery. Feelings of guilt and shame can give the person permission to continue to use drugs, and may result in people dwelling on negative feelings about themselves, or denying or escaping from these feelings by using. People lose energy when they give themselves guilt and shame‐producing messages and may use drugs to give themselves a false sense of euphoria to change their mood. Discuss strategies for healing guilt and shame such as: • Recognise your guilt and shame. • Give yourself time to feel better about yourself. • Accept your limitations. • Talk about your feelings of guilt and shame. • Use a 12‐step program. • Make amends (steps 8 and 9). • Seek forgiveness. Step 7 – Finish up by filling in the sections on Shame and Guilt on Worksheet 11: Feelings of Anger, Loss, Shame and Guilt. Step 8 – Distribute Worksheet 12: Pleasant Events Calendar and go through this with the group. This is the homework task for this week. Ask the group to commence the next day and to record one pleasant event each day for the following six days before meeting again. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 71 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Tip Sheet 9: Fight or flight response, is one of the Tip Sheets in the next session (Module 5). This might be used in the time between sessions in a Concept or other Educational Group to help clients prepare for the next session, which teaches strategies to deal with anxious thoughts and feelings. Understanding what causes stress, both real and imagined fears and threats, helps us to understand how we can control these feelings and not allow them to rule our lives or to act in ways that are counter‐productive. Put another way, to understand how we can increase our Vitality, rather than our Suffering. Page 72 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Module 5. Aim: To learn how to deal with anxious thoughts and feelings. Materials needed for Module 5: •
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Tip Sheet 9: Fight or Flight Response Tip Sheet 10: Coping with Anxiety: Bodily Symptoms Tip Sheet 11: (Changing) The Anxiety Cycle Worksheet 8: Unhelpful thinking patterns Worksheet 9: Self‐monitoring record Worksheet 13: Anxious Automatic Thoughts Questionnaire Worksheet 14: Coping Statements for Anxiety Key elements of Module 5. The value of relaxation and meditation has been highlighted in previous sessions. The 3‐Minute Breathing Space is a brief mindfulness meditation that will assist clients to expand their awareness and to reconnect with the present moment – the here and now. This should be used at the commencement or the end of each of the remaining sessions. Step 1 ‐ The 3‐Minute Breathing Space ‐ Basic Instructions 1. AWARENESS Come into the present moment by deliberately adopting an upright and dignified posture. If possible, close your eyes. Then notice: “What is my experience right now… in bodily sensation…in feelings...in thoughts?” Acknowledge and register your experience, even if it is unwanted. Allow yourself to be present, to meet yourself, gently and with acceptance. 2. GATHERING Then, gently bring your full attention to breathing, to each breath in and to each breath out, as they follow, one after the other. If sound is a better anchor for you, then gently bring your awareness to the sound around you. Use your breath (or sound) as an anchor to bring you into the present and help you tune into a state of awareness and stillness. 3. EXPANDING Gently expand the field of your awareness around your breathing, so that it includes a sense of the body as a whole… your posture … and facial expression. Now gently bring your attention back into the room, and when you are ready, open your eyes. Move your head from side to side, lift your shoulders, and let them drop. Stretch as you stand up, and when you have stretched, sit back down again. How do you feel? The breathing space provides a way to step out of automatic pilot mode and reconnect with the present moment. The key skill using Mindfulness Based Cognitive Therapy (MBCT) is to maintain awareness in the moment. Nothing else. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 73 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Step 2 – Review homework from last week, Worksheet 12: The Pleasant Events Calendar. What did everyone find when they became aware of pleasant events? Was it difficult? Ask volunteers to provide feedback. Step 3 ‐ Understanding cravings as anxious thoughts provides another way of looking at and understanding some of our thinking patterns. These thoughts may then make us even more anxious. When we are anxious we often imagine unpleasant and even frightening things are going to happen. We may then look ahead and try to foresee and avoid problems. In anxious thinking, the balance between expecting the worst and expecting good things is disturbed (Taylor, 2009). This often leads to worrying about things before they happen – expecting the worst. When we expect the worst, we often tell ourselves that we won’t be able to cope. Here are some examples – and different ways of seeing the same situation. Brainstorm with the group and write the responses on the whiteboard: A disagreement with a peer... Person A Person B OK, so we have a different point of view. That’s OK She doesn’t agree with me It was an interesting discussion – we see things She thinks what I said was stupid I am an idiot, I shouldn’t have said anything differently I can’t handle this I don’t really agree, but it’s interesting I’m getting out of here If we disagree, we can sort it out, talk about it Result = Anxiety/Panic Result = Interested/Stimulated Step 4 – Recognising anxious thought patterns will be similar to recognising unhelpful thinking styles – and there are many overlaps. Distribute Worksheet 8: Unhelpful thinking patterns. Becoming anxious is the feeling that often results from the thought. Ask the group, which of the following examples of anxious thinking patterns apply to them: • Thinking the worst – e.g., “I’ve got a pain in my chest, there’s probably something wrong with my heart”. • Predicting that the worst will happen – e.g., “They won’t like me, they’ll think I’m stupid”. • Exaggerating negatives – e.g., “I made a complete mess of it, it was an absolute disaster”. • Overgeneralising – If something happens once, you think it will happen again. e.g., Feeling anxious when you go into town. “I always get anxious when I go out”. • All or nothing thinking ‐ e.g., “Unless I can do this without any mistakes, I’m a complete failure”. • Imagining you know what others are thinking ‐ e.g., “I can tell that he is thinking that I’m a complete idiot”. Step 5 – Worksheet 13: Anxious Automatic Thoughts Questionnaire. This is an optional activity, and you may therefore decide not to do this in the session. Instead, it might be used individually with particular clients outside the session to assist them to understand more about their anxious thoughts, and the value they place on these thoughts – i.e., do the degree of belief in the thought. If you decide to use the questionnaire in the group, distribute to participants and ask each person to complete them. You may find it is easier to do the first column (Frequency) first and then come back to the second column (Degree of belief). Read out the instructions and demonstrate this by doing the first 2 questions together so that everyone understands the task. Alternatively, the whole questionnaire might be used as a group exercise. Page 74 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities The questionnaire is scored by adding up the numbers circled. The higher the score, the greater the anxiety and the degree of belief in the thoughts. The total score is not as important in this exercise as understanding the source of the person’s anxiety and their belief in that thought. Hence, if someone often has a particular thought, but doesn’t hold a strong belief in it, they are able to let it pass through and not become anxious. However, if there is a strong degree of belief in the thought, then this should be explored. Step 6 – Ask each person to provide feedback on just one item. What did they find out, and how does it tie back to the earlier discussion about anxious thought patterns? Can they associate it with one of the patterns discussed before? For example: • Item 2: If I get criticised it means that I am wrong – Exaggerating negatives. • Item 11: I can tell that people will evaluate me negatively ‐ Imagining you know what others are thinking. • Item 14: Being anxious is a sign of weakness ‐ All or nothing thinking. Step 7 ‐ Coping with anxiety begins with an understanding of the body's stress response. The body undergoes three stages of stress. These stages are as follows: 1. Fight or Flight: During this stage, the body perceives threatened danger. A surge of energy overtakes the body, enabling the person to fight off the threat or flee from the danger at hand. 2. Resistance: This stage occurs when danger remains beyond the fight or flight period. The body secretes several hormones in order to mobilise the body during long‐term stress. 3. Exhaustion: If the body successfully completes the first two stages, it will enter a third stage, exhaustion. This is a time when the fatigued body replenishes itself. The Fight or Flight Response is the body’s response to perceived threat or danger. During this reaction, certain hormones like adrenalin and cortisol are released, speeding the heart rate, slowing digestion, shunting blood flow to major muscle groups, and changing various other autonomic nervous functions, giving the body a burst of energy and strength. Originally named for its ability to enable us to physically fight or run away when faced with danger, it’s now activated in situations where neither response is appropriate, like in traffic or during a stressful interaction. When the perceived threat is gone, systems are designed to return to normal function via the relaxation response, but in our times of chronic stress, this often doesn’t happen enough, causing damage to the body. Distribute Tip Sheet 9: Fight or Flight Response. Step 8 ‐ Coping With Anxiety ‐ When Does Stress Become a Problem? Coping with anxiety is a necessity in our modern fast‐paced world. Busy lifestyles, intensified by many daily problems like traffic jams, money problems, work problems and relationship difficulties keep many people in chronic states of stress. Stress becomes a problem when a person undergoes a sense of prolonged danger. During the fight or flight and resistance stages, the body produces many helpful hormones. However, excessive amounts of these same substances can cause damaging effects to the body. For instance, adrenaline helps with energy production during stressful periods. However, prolonged use of adrenaline by the body leads to a weakening of the heart. Cortisol, which is released during the resistance stage, © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 75 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities raises blood pressure and blood sugar levels and may narrow artery walls by increasing blood platelets. During prolonged stress, the body rarely has time to replenish itself. The body remains in a cycle of fighting, fleeing, and resisting, with little or no time to rest. This affects the body's sleep cycle, only increasing the body's fatigue and decreasing full restoration. Coping with anxiety begins with understanding the symptoms of excess stress. These symptoms include: exhaustion, sleep problems, tension headaches, constant worry, dark circles under the eyes, bowel disturbances, lowered immune function, irritability or angry outbursts, lack of concentration, and so on. (These are described in Tip Sheet 10: Coping with Anxiety: Bodily Symptoms). Step 9 – Distribute Tip Sheet 11: (Changing) The Anxiety Cycle and Worksheet 14: Coping Statements for Anxiety. Tip Sheet 11: (Changing) The Anxiety Cycle describes the way in which we respond to long‐held beliefs about our response to anxiety‐provoking situations. Changing this cycle can be accomplished by putting in place coping mechanisms. Discuss each of these. What other mechanisms or strategies can people think of? Refer to Worksheet 14: Coping Statements for Anxiety. Where in the Anxiety Cycle could some of these be used? Step 10 – For homework during this week, ask clients to again fill out Worksheet 9: Self‐monitoring record. Provide a new copy. There are no Tip Sheets included in the next module, but it may be useful to check with participants during the intervening days or week to see how they are going with the homework task. Page 76 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Module 6. Aim: To understand and acknowledge core beliefs and values. Materials needed for Module 6: •
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Personal Values Card Sort Worksheet 15: Ranking of Personal Values Card Sort Worksheet 16: Personal Values Exercise Worksheet 17: Values ‘Bull’s Eye’ Worksheet 18: Cultivating Positive Affirmations and Vision Key elements of Module 6. Step 1 – Review last week’s homework: Self‐monitoring record. Did anyone notice any changes between this week and the last time this exercise was done? What were they? Discuss. Step 2 – Values: What is important in my life? It is possible that members of the group, your client or clients have never really stopped to consider what is important in their lives – their core beliefs and values, and (looking at that word ‘value’ from another perspective) what it is they value in life. Often we are unaware of our values because we have never thought much about them. But as people come into treatment, this becomes a time for re‐evaluation, especially if people are beginning to feel, or have felt, unfulfilled in their lives. If this is the case, it is often a sign that what we are doing does not match up with our core values. This module will use some exercises to help each person assess what really matters to them. Identifying personal values will make it much easier for each person to work out how they need to adjust what they are doing in their lives in order to live by their values, or, from another perspective, the things which they value. Step 3 ‐ Who inspires you? Ask each person to consider the following questions and to write down their responses. These will be discussed in pairs or small groups. ‐
If you could meet up with any famous character from history, a favourite character from literature, or from a movie, who would it be? ‐
What is it about this person that inspires you? ‐
What would you like to ask them? ‐
What characteristics of theirs would you like to adopt for yourself? ‐
What does this tell you about yourself? Ask for feedback to the larger group. Make a list on the whiteboard of the characteristics which were highlighted by members of the group. Did any of these seem surprising? What is the characteristic that most people value in others? Step 4 – Personal Values Card Sort This has been adapted from the one developed by Miller, C’de Baca, Matthews and Wilbourne (2001) and is an activity that can be helpful when thinking about making changes. It is a way to identify things that are really important to us, and learn a bit about ourselves. The personal values cards are provided with the worksheets in this manual. Before starting, these will need to be photocopied off and cut these into a set of cards for each participant. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 77 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Give each participant a set of cards with the three anchor cards (‘Not Important to Me’; ‘Important to Me’; and ‘Very Important to me’) on the top of the pack. 1. Ask each person to place the three anchor cards in order in front of them (‘Not Important to Me’ on the left; ‘Important to Me’ in the middle and ‘Very Important to me’ on the right). 2. Ask them to shuffle the 83 value cards; keeping the 3 blank cards separate. 3. Instruct the participants to sort the cards using the following script: • “You placed the three title cards in front of yourself — ‘Not Important to Me’, ‘Important to Me’ and ‘Very Important to me’. In your hands you have a stack of 83 cards. Each card describes something that may represent a personal value for you. I would like you to look at each card and place each card under one of the three title cards. • There are also three blank cards. If there is a value which is not on the printed cards, and which you would like to include, write it on the card and put it in whichever pile you would like. I would like you to sort all 83 cards, but whether you use the three additional cards is optional. The only rule is that you can have no more than 15 cards under the Very Important stack. After you have finished this part, I will ask you to do one other small task. Do you have any questions?” 4. When participants indicate they are finished with the sorting, ask them to check the ‘Very Important’ deck to make sure there are no more than 15 cards under this deck. 5. Read the following: • “For the second task, I’d like you to focus on the top values you chose and sort them from 1 to n (total number participant has in the most important pile—no more than 15) using the ranking sheet. In this spot (point to #1) you will put the card that is your top value. Then you will put your second top value here (point to #2). Then I want you to write what this value means to you, like the example. Do you have any questions?” 6. Distribute Worksheet 15: Ranking of Personal Values Card Sort. When participants indicate they are finished rank ordering the most important pile, check to make sure that the number 1 value is at the top, and they are in order from the most important down to the bottom of the list and that they understand why the value is important to them. Ask the group if anyone had any surprises doing that exercise. When they look at the way in which they ranked their values cards, do they think this has changed over the past years? What about since they first came into the program? What are the values which are now at the top of their list? Step 5 ‐ Distribute Worksheet 16: Personal Values Exercise. This task will follow on from the previous one, and now that each person has been able to think their values through a little clearer, they will have a better idea of where they sit in relation to each of these. The worksheet has two parts – go over the first page with the client(s) so that each part is understood. Discuss this, when everyone feels comfortable with the task, ask the group to fill out page 2 with their responses. Explain they do not have to share their responses, but you will ask the Page 78 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities group to feedback their general response. What did they find out about their values in each of the categories? How did this tie into the first task? Step 6 – Distribute Worksheet 17: Values ‘Bull’s Eye’. This exercise will take the values exercise a step further, by asking each person to think about each area: 1. Relationships: includes partner, children, parents, relatives, friends, and other social contacts. 2. Work/Education: includes workplace, career, education, skills development, etc. 3. Personal Growth/Health: may include religion, spirituality, creativity, life skills, exercise, nutrition, and/or addressing health risk factors like smoking, alcohol, drugs or overeating etc. 4. Leisure: includes how you play, relax, stimulate, or enjoy yourself; activities for rest, recreation, fun and creativity. Placing an X in the appropriate spot on the Bull’s Eye – how close to the target are you living in terms of your values? This exercise is not about being ‘right’ or ‘wrong’ but about making an honest appraisal of your life and thinking about whether or not you want to make any changes. Remember that it is likely that some of your values will probably change with time, and this will become more and more apparent as you continue in recovery and start to re‐evaluate what is important to you. So if you find that what was important to you when you were at school, or starting work is less significant now, that's OK. Be prepared to make an adjustment in your life to allow for these changes. Step 7 ‐ Worksheet 18: Cultivating Positive Affirmations and Vision. The purpose of this final task is to help each person recognise their internal and external values and to begin to develop positive affirmations. Step 8 – Finish the group with the 3‐Minute Breathing Space 1. AWARENESS Come into the present moment by deliberately adopting an upright and dignified posture. If possible, close your eyes. Then notice: “What is my experience right now… in bodily sensation…in feelings...in thoughts?” Acknowledge and register your experience, even if it is unwanted. Allow yourself to be present, to meet yourself, gently and with acceptance. 2. GATHERING Then, gently bring your full attention to breathing, to each breath in and to each breath out, as they follow, one after the other. If sound is a better anchor for you, then gently bring your awareness to the sound around you. Use your breath (or sound) as an anchor to bring you into the present and help you tune into a state of awareness and stillness. 3. EXPANDING Gently expand the field of your awareness around your breathing, so that it includes a sense of the body as a whole… your posture … and facial expression. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 79 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Now gently bring your attention back into the room, and when you are ready, open your eyes. Move your head from side to side, lift your shoulders, and let them drop. Stretch as you stand up, and when you have stretched, sit back down again. How do you feel? The breathing space provides a way to step out of automatic pilot mode and reconnect with the present moment. The key skill using Mindfulness Based Cognitive Therapy (MBCT) is to maintain awareness in the moment. Nothing else. No homework tasks are provided with this module, since Module 7 on Relapse Prevention may not be presented directly following Module 6. Page 80 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Module 7. Aim: To develop a coping plan and relapse prevention strategies for high risk situations. Materials needed for Module 7: •
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Tip Sheet 12: Ten Most Common Relapse Dangers and High‐Risk Situations Worksheet 19: My Relapse Dangers Worksheet 20: Problem Solving Worksheet 21: Relapse Prevention Plan Key elements of Module 7. Step 1 – Start the group with the 3‐Minute Breathing Space 1. AWARENESS Come into the present moment by deliberately adopting an upright and dignified posture. If possible, close your eyes. Then notice: “What is my experience right now… in bodily sensation…in feelings...in thoughts?” Acknowledge and register your experience, even if it is unwanted. Allow yourself to be present, to meet yourself, gently and with acceptance. 2. GATHERING Then, gently bring your full attention to breathing, to each breath in and to each breath out, as they follow, one after the other. If sound is a better anchor for you, then gently bring your awareness to the sound around you. Use your breath (or sound) as an anchor to bring you into the present and help you tune into a state of awareness and stillness. 3. EXPANDING Gently expand the field of your awareness around your breathing, so that it includes a sense of the body as a whole… your posture … and facial expression. Now gently bring your attention back into the room, and when you are ready, open your eyes. Move your head from side to side, lift your shoulders, and let them drop. Stretch as you stand up, and when you have stretched, sit back down again. How do you feel? The breathing space provides a way to step out of automatic pilot mode and reconnect with the present moment. The key skill using Mindfulness Based Cognitive Therapy (MBCT) is to maintain awareness in the moment. Nothing else. Step 2 – This module will focus on assisting clients to anticipate potential high risk situations that might lead to a lapse and to develop concrete coping plans for each of these situations. It is also important to develop a plan for what to do in the event of an unexpected high risk situation arising. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 81 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Research studies and clinical experience have shown commonalities across relapse situations, with personal issues, including family relationships; issues of social interaction and drug‐related concerns all nominated as triggers to relapse (Magor‐Blatch & Rickwood, 1998). Ask the group members to state what they think are the most common relapse dangers they face in their recovery. Review the most common categories of relapse dangers that we know about from clinical work and research (Lee, et.al., 2007). These relapse dangers include: • Upsetting or negative emotional states (anger, anxiety, boredom, depression, guilt, loneliness, etc.). • Social pressures to get stoned or use chemicals. • Interpersonal problems or relationship conflicts. • Lack of social supports or a recovery network. • Inability to solve problems or manage stress. • Strong cravings or urges to use drugs, including alcohol. • Lack of structure in daily life or involvement in a regular program of recovery. • Positive feelings and a desire to celebrate. • The coexistence of a major psychiatric disorder along with the addiction. • Failure to follow through with a recovery program and attend counselling sessions and self‐help groups (NIDA, 2003). Distribute Worksheet 19: My Relapse Dangers. A vital step in preventing relapse is to identify high risk situations in advance, and to prepare for them. Remember: We don’t practice fire drills so that we can go around lighting fires, but so that we know what to do to protect ourselves should a fire break out. As clients adjust to new lives without drugs, develop relationships and take on new responsibilities, life will become stressful. In the past, alcohol and other drugs have been part of the person’s coping mechanism. Without them, new ways of coping need to be developed. Ask the group: “What kinds of people/situations/places/things will make it difficult for you in the future? What situations do you consider to be high‐risk? How do you know what the warning signs are? Remember, relapse doesn’t just occur when you pick up, but sometime before. How will you begin to recognise the warning signs?” Ask each group member to identify two personal relapse dangers and coping strategies to handle them. Have each member review their answers with others in the group. Ask other group members to give feedback to the member who is sharing their relapse dangers and coping strategies. Provide Tip Sheet 12: Ten Most Common Relapse Dangers and High‐Risk Situations to group members and ask what are the relapse dangers with which they identify. Discuss ways to cope with common relapse dangers without using. Step 3 ‐ Developing a coping plan, which might include: • A list of emergency numbers. • A reminder of negative consequences of using (e.g., on a card that the client can keep in their wallet and read when needed). • A set of positive thoughts that will assist in maintaining gains (e.g., on a card). • A set of reliable distracters, at least some of which need to be immediately accessible. Page 82 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities •
A list of safe places to ‘ride out’ a crisis (Lee, et.al., 2003). Step 4 ‐ The basic steps in Problem Solving are: 1. Recognise the problem. 2. Identify and specify the problem. 3. Consider various approaches to solving the problem. 4. Select the most promising approach. 5. Assess the effectiveness of the approach. 6. If ineffective, select another approach and assess. Use Worksheet 20: Problem Solving. Ask clients to identify two problems, one that is closely related to past drug use and one less related and work through the problem solving steps for each. Step 5 ‐ Relapse prevention Use Worksheet 21: Relapse Prevention Plan to identify early warning signs of relapse. These can be based on an analysis of previous relapses, but may also relate to the anticipation of new situations in recovery that may be uncomfortable. List the general coping strategies which the person already has in place, and the rewards for not using that these offer. However, not all situations can be anticipated in advance, therefore it is useful to think about some general coping strategies that can be called on – like calling a friend, a peer, a sponsor. These will be the skills that are most effective to develop. Identify any additional skills required to help prevent relapse and ask the group to offer suggestions about how to acquire these. To consolidate the use of the plan, discuss with the client(s) when to use the plan and how to monitor early warning signs (Lee, et. al., 2003). Step 6 ‐ Maintaining Recovery 1. Stress the importance of keeping recovery plans up‐to‐date and working at long‐term recovery. 2. Discuss the importance of continuing to adhere to one’s recovery goals and how effective this can be in maintaining abstinence. 3. Reinforce the need for continuing to participate in self‐help groups and using the ‘tools’ of recovery on a daily basis. 4. Ask the group members to identify the benefits of ongoing participation in a recovery program following completion of professional treatment. Some examples include: • Receiving continued help and support from others in recovery. • Actively working at a program of recovery reduces relapse risk. • Involvement in recovery, especially support groups, is a constant reminder of the seriousness of addiction and the importance of maintaining recovery. • Staying sober puts the recovering person in a position in which he or she is able to continue to make positive changes in self and lifestyle. • Many problems and issues emerge over time, even if one is sober from alcohol or clean from drugs. Participating in a recovery program can make the person feel better prepared to handle these issues or problems. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 83 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities 5. Discuss the length of time one should stay involved in a recovery program such as AA or NA. This varies considerably among recovering individuals, with many staying involved for years or even throughout their lives. Remember, pushing through the reluctance and barriers to attending support groups is important. The excuses (“I’m different”, “I don’t really identify”, “My issues/story are nothing like theirs”) are often just the excuses we use to keep ourselves on the outer – and ultimately to feel so bad that we give ourselves permission once again to use. 6. Ask the group to identify the ‘tools’ of recovery that they can use on a regular basis, once they are finished with the group sessions. These tools may include the following: • Attending AA, NA, or other self‐help meetings. • Talking with a sponsor or other members of self‐help programs. • Sharing social or recreational activities with friends. • Avoiding high‐risk people, places, or situations when possible. • Attending aftercare group counselling sessions or talking individually with a counsellor or therapist. • Using techniques learned to fight off thoughts of drinking alcohol or using other drugs or to fight off strong cravings. • Using positive affirmations by reminding oneself of the benefits of sobriety and that all the time and effort put into is worthwhile. • Getting physical exercise. • Focusing on one of the 12 steps. • Repeating and thinking about a recovery slogan. • Reading specific recovery literature or a meditation guide. • Writing in a recovery journal or workbook. • Participating in pleasant activities that don’t involve alcohol or other drugs. • Doing something nice for someone else as a way of ‘giving back’. • Reviewing one’s plan for recovery at the beginning of each day. • Evaluating how the day went to review positive growth and identify problems needing attention. • Regularly reviewing relapse warning signs to catch them early. 7. Group members can also state how these various recovery tools can help their ongoing recovery, such as the following: • Helping to identify problems and warnings signs early. • Becoming aware of behaviours and strategies to help in recovery. • Using the support of others in recovery. Page 84 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Section 4: Worksheets © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 85 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Page 86 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Week 5 Week 4 Tuesday Wednesday Thursday Friday Saturday Sunday Week 3 Week 2 Week 1 Monday 1. Provide anchors for the client by first filling in public holidays, significant personal events and other dates on the calendar. 2. Assist the client to work back from last day of use and complete ALL drug use for each day. Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 1: Timeline Follow Back Page 87 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 2: Stages of Change Ladder The rungs on this ladder can be used to represent where you are now in regard to your ATS use. Tick the rung that best describes where you are right now. I have recently been to detox. I’m ready to come into the TC Maintenance I’m ready to go to detox, and then I want to come into the TC Action I have made real plans to quit or cut down and that includes detoxing Preparation I think I might need to quit or cut down, but I'm not sure I want to or that I’m ready for it Contemplation I'm happy using and don't feel the need to quit or cut down Precontemplation Adapted from Lee, et. al. (2007), and from original work of Biener & Abrams (1991) Page 88 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 3: Psychosis screener The Psychosis Screener is clinician administered. Only ask the supplementary questions (1a, 2a and 3a) if the client answers YES to the main question. 1. In the past 12 months, have you felt that your thoughts were being directly interfered with or controlled by another person? Yes (go to 1a) No (go to 2)
1a. Did it come about in a way that many people would find hard to believe, for instance, through telepathy? Yes No 2. In the past 12 months, have you had a feeling that people were too interested in you? Yes (go to 2a) No (go to 3)
2a. In the past 12 months, have you had a feeling that things were arranged so as to have a special meaning for you, or even that harm might come to you? Yes 3. Do you have any special powers that most people lack? No
Yes (go to 3a) No (go to 4)
3a. Do you belong to a group of people who also have these special powers? Yes (‐1 point) No 4. Has a doctor ever told you that you may have schizophrenia? Yes No Scoring: Each question answered 'yes' is scored 1 point, except question 3a which is scored ‐1 if answered 'yes'. Add each score. A cumulative score of 3 or more indicates potential presence of significant psychotic symptoms. Source: Lee, et.al. (2007); adapted from Degenhardt, Hall, Korten, Morgan, and Jablensky (2005). © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 89 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 4: Lifestyle issues causing problems in my life These are the lifestyle issues which some people have nominated as the reason to give up their use of ATS (methamphetamine and other amphetamine‐type stimulants). Put a tick in the box opposite each of the factors if they apply to you – i.e., it was one of the reasons you decided to seek treatment. Argued with others Lost my temper Had reduced work/study performance Did something under the influence of drugs that I later regretted Took sick leave/did not attend classes Couldn’t remember what happened the night before Damaged some of my own property Had unprotected sex No money left for any luxuries Passed out Upset a family relationship Stole property No money for food or rent Damaged a friendship Got into debt/owing money Ended a personal relationship Got arrested Physically hurt someone else Got a traffic ticket Spent some nights sleeping rough (i.e., living on the streets) Sacked / lost business /quit study course Had a car crash Had sex and later regretted it Charged with a driving offence Was kicked out of where I was living Physically hurt myself Overdosed on drugs Was sexually harassed Was sexually assaulted Any others? Please record any other issues on the back of this form. Page 90 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 5: Decisional balance Good things about continuing to use Less good things about continuing to use Less good things about stopping using Good things about stopping using © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 91 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 6: Vitality vs. Suffering Permission given to adapt from Russ Harris (2007) www.actmindfully.com.au YOUR STRUGGLES: What are the main thoughts and feelings you struggle with? What thoughts and feelings pull you into a struggle with life, health, happiness, yourself, or others? Write these down inside the two circles. What do you do when these thoughts and feelings show up? On the top half of the page, list things you do that increase your VITALITY – and on the bottom half, list things you do that increase your SUFFERING. VITALITY: (list all the positive things you have done when these thoughts and feelings showed up – i.e., things that improved your life, health, happiness, relationships and vitality in the long term). Remember, sometimes these things might seem hard in the short term (like you are increasing your suffering instead of vitality) but they will be increasing your vitality over time. Body
Feelings, sensations, urges, cravings, symptoms of physical illness
Mind
Thoughts, memories, beliefs, worries, self‐judgements
SUFFERING: (list all the negative things you have done when these thoughts and feelings showed up – i.e., things that wasted your time, energy, and money, damaged your health, hurt your relationships, or worsened your life in the long term). Remember, sometimes these feel like they are increasing your vitality – but that will be just in the short term, in the long term they actually increase your suffering. Page 92 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 7: Vitality vs. Suffering Diary What I did that lead to VITALITY What I did that lead to SUFFERING (improving life, health, wellbeing in the long (worsening life, health, wellbeing in the long term. term. Painful thoughts, feelings, urges, memories that showed up today. Permission given to use by Russ Harris (2007) www.actmindfully.com.au © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 93 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 8: Unhelpful thinking patterns 1. Catastrophising – People with this pattern of thinking tend to give too much meaning to situations. So, you exaggerate the importance of things ‐ making mountains out of mole hills or convincing yourself that if something goes wrong it will be totally unbearable and intolerable. 2. Mind reading – This means making assumptions about how others feel, arbitrarily concluding that someone is reacting negatively to you, without checking this out. 3. Overgeneralisation ‐ Making broad ‘always’ or ‘never’ statements. You see a single negative event as a never‐ending pattern of defeat. 4. Labeling and Mislabeling ‐ This is an extreme form of overgeneralisation. Instead of describing your error, you attach a negative label to yourself: “I’m a loser.” When someone else’s behaviour rubs you the wrong way, you attach a negative label to him: “He’s a pathetic wimp.” Mislabeling involves describing an event with language that is highly coloured and emotionally loaded. 5. Selective abstraction ‐ Focusing on one small detail and interpreting the entire experience by that detail. 6. Personalisation ‐ Excessively blaming yourself for events over which you did not have complete control. You see yourself as the cause of some negative external event which in fact you were not primarily responsible for. This means that you will often confuse facts with feelings – if someone else is in a bad mood, you will think it’s something you did – when it may have nothing to do with you at all. 7. ‘Should’ fallacies ‐ You try to motivate yourself with ‘shoulds’ and ‘should nots’, as if you had to be whipped and punished before you could be expected to do anything. ‘Musts’ and ‘oughts’ are also offenders. "I should be better”. The emotional consequence is guilt. ‘Should’ statements directed to others result in anger, frustration, and resentment. “They should care about me much more than they do." This type of thinking often leads to feelings of guilt and sets you up to be disappointed, particularly if the thoughts are unreasonable. 8. Minimisation ‐ Reducing an important event into something less important. This includes inappropriately shrinking things until they appear tiny (your own desirable qualities or the problems in your life so that you don’t have to face them). This is also called the ‘binocular trick’. 9. Black and white thinking – This is All‐Or‐Nothing Thinking ‐ You see things in black‐and‐white categories, so that things are either all good or all bad, with nothing in between – or no balance. Do you have strict rules about yourself or your life? Are you rigid in your thinking? If your performance falls short of perfect, do you see yourself as a total failure? 10.Mental Filter ‐ You pick out a single negative defeat and dwell on it exclusively so that your vision of reality becomes darkened, like the drop of ink that colors the entire glass of water. 11.Disqualifying the positive ‐ You dismiss positive experiences by insisting they ‘don’t count’ for some reason or other. In this way you can maintain a negative belief that is contradicted by your everyday experiences. Page 94 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities 12.Jumping to conclusions ‐ You make a negative interpretation even though there are no definite facts that convincingly support your conclusion. This means that you may also act like a mind reader or a fortune teller believing that you know what the other person is feeling or thinking without checking it out. You also think that things will turn out badly, and that this will probably always be the case. 13.The fortune teller error ‐ You anticipate that things will turn out badly, and you feel convinced that your prediction is an already‐established fact. 14.Emotional Reasoning ‐ You assume that your negative emotions necessarily reflect the way things really are: “I feel it, therefore it must be true”. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 95 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 9: Self monitoring record This diary will help you understand the differences between thoughts and feelings.
1. Start with A. This is called the Activating Event. 2. Then go to B, which stands for Belief, and write down your thoughts. 3. Now go to C. What were the Consequences? A ‐ Activating Event
B – Belief
C ‐ Consequences Write down the Write down your thoughts. Ask Write down a situation, an event, words that describe how you feel. yourself, “What was I thinking?” thought or mental picture that Underline the one that is most associated with the activating made you feel upset. event. Find the most distressing hot thought and underline it.
4. Now think back to the Unhelpful Thinking Styles that we have discussed. Do you recognise any unhelpful thinking styles you might have been using? 5. Finally, look at D, which stands for Detective Work and Disputation. In the first column, think about the hot thought which you recorded under Consequences. 6. Then go to the second D column – Disputation – What other ways are there of viewing this situation? Unhelpful Thinking Styles D – Disputation D ‐ Detective Work Think about Do you recognise any unhelpful What other ways are the hot thought which you recorded under Consequences. thinking styles you might have there of viewing this situation? Is Ask yourself, “What is the factual been using? (e.g., Mental filter, there another way of looking evidence for and against my hot Personalisation, Catastrophising at it, or another explanation? thought?” Record this.
etc?) Page 96 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 10: Understanding how we experience Feelings From the list of feelings below, choose a feeling that you have experienced in the past week. Mark on the diagram where in your body you experienced the feeling. Choose an appropriate coloured pencil or crayon to mark this on the diagram. For example, if you chose ANGRY perhaps your heart raced, your face turned red or you began to sweat. Jealous Glad Embarrassed Depressed Relieved Fearful Anxious Disappointed Tired Content Hurt Pride Amused Grateful Sad Guilty Disgusted Thoughtful Happy Disturbed Worried Lonely Shame Surprised Nervous Lost Angry Confused Pride Excitement Miserable Bitter Calm Joy Helpless © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 97 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 11: Feelings of Anger, Loss, Shame and Guilt Anger: Some of the positive ways I can express my feelings of anger Loss: Thinking back over my life, how have some of my losses affected me? Shame: This is my tendency to feel bad about myself following a specific event. Guilt: I feel guilty when I feel bad about a specific behaviour or action. Page 98 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Example: Working in the garden ‐ stopping, hearing a bird sing. What was the experience? Yes. Were you aware of the pleasant feelings while the event was happening? What moods, feelings and thoughts accompanied this event? Lightness across the face, "That's good." aware of shoulders "How lovely (the bird)." dropping, uplift of "It's so nice to be corners of mouth. outside." How did your body feel, in detail, during this experience? It was a small thing but I'm glad I noticed it. What thoughts are in your mind now as you write this down? Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Be aware of a pleasant event at the time it is happening. Use the questions to focus your awareness on the details of the experience as it is. Worksheet 12: Pleasant Events Calendar Adapted from Zindel Segal, Mark Williams, and John Teasdale (2002), Mindfulness‐Base Cognitive Therapy for Depression: A New Approach to Preventing Relapse. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 99 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 13: Anxious Automatic Thoughts Questionnaire Listed below are a variety of thoughts that pop into people's heads. •
Read each thought carefully and indicate how frequently, if at all, the thought occurred to you over the last week, by circling the answer in the left column. •
Then, indicate how strongly, if at all, you tend to believe that thought when it occurs by circling your answer in the right column. FREQUENCY 1 = "not at all" DEGREE OF BELIEF 1 = "not at all"
ITEMS 5 = "all the time" 5 = "totally" 1 2 3 4 5 1.
When people look at me they are examining what I do
1 2 3 4 5
1 2 3 4 5 2.
If I get criticized it means that I am wrong.
1 2 3 4 5
1 2 3 4 5 3.
If I make a mistake that means that I am stupid.
1 2 3 4 5
1 2 3 4 5 4.
If I don't agree with people they won't like me.
1 2 3 4 5
1 2 3 4 5 5.
To be a good person I have to be nice to everyone.
1 2 3 4 5
1 2 3 4 5 6.
If someone is hurt or offended by what I do, this means 1 2 3 4 5
I am a bad person. 1 2 3 4 5 7.
If I show emotion it means that I am weak.
1 2 3 4 5
1 2 3 4 5 8.
People will think that there is something wrong with 1 2 3 4 5
me if they see that I am anxious. 1 2 3 4 5 9.
The opinions of other people about me are very 1 2 3 4 5
important. 1 2 3 4 5 10. I'm afraid that I look or sound silly to other people
1 2 3 4 5
1 2 3 4 5 11. I can tell that people will evaluate me negatively.
1 2 3 4 5
1 2 3 4 5 12. I have to be very careful about what I say in case I 1 2 3 4 5
offend someone. 1 2 3 4 5 13. Approval is very important to me.
1 2 3 4 5
1 2 3 4 5 14. Being anxious is a sign of weakness.
1 2 3 4 5
1 2 3 4 5 15. When people see me behave like this they will talk 1 2 3 4 5
badly of me to others. 1 2 3 4 5 16. If someone is late, I assume there has been an 1 2 3 4 5
accident. We begin to recognise unrealistic, frightening anxiety producing thoughts and learn simply to be present with them without attaching to them and believing them, ignoring them, or judging them and pushing them away. Taylor (2008); Adapted with permission from Hollon and Kendall (1980). Page 100 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 14: Coping Statements for Anxiety Purpose: to put a stop to the thoughts that lead to anxiety, and to replace those thoughts with realistic, rational thoughts. When these self‐statements are practiced and learned, your brain takes over automatically. This is a form of conditioning, meaning that your brain chemistry (neurotransmission) actually changes as a result of your new thinking habits. The first thing to do is to put a stop to the thoughts. Remind yourself that the thoughts you are having are not healthy or helpful and you have decided to move in a better direction and learn to think differently. Then, pick two or three statements from the list below that seem to help you, and repeat them to yourself OUT LOUD each day. (You don’t have to believe them fully yet – that will happen later). When Anxiety is Near: General Statements: 1. I’m going to be all right. My feelings are not always rational. I’m just going to relax, calm down, and everything will be all right. 2. Anxiety is not dangerous ‐ it’s just uncomfortable. 3. Right now I have some feelings I don’t like. They’re not real, because they are disappearing. I will be fine. 4. Right now I have feelings I don’t like. They will be over soon and I’ll be fine. For now, I am going to focus on doing something. 5. That picture (image) in my head is not a healthy or rational picture. Instead, I’m going to focus on something healthy like _________________________. 6. I’ve stopped my negative thoughts before and I’m going to do it again now. I am becoming better and better at deflecting these negative thoughts and that makes me happy. 7. So I feel a little anxiety now, SO WHAT? It’s not like it’s the first time. I am going to take some deep breaths and keep on going. This will help me continue to get better." Statements to use when preparing for a Stressful Situation: 1. I’ve done this before so I know I can do it again. 2. When this is over, I’ll be glad that I did it. 3. This may seem hard now, but it will become easier and easier over time. 4. I think I have more control over these thoughts and feelings than I once imagined. I am very gently going to turn away from my old feelings and move in a new, better direction. Statements to use when I feel overwhelmed: 1. I can be anxious and still focus on the task at hand. As I focus on the task, my anxiety will go down. 2. Anxiety is an old habit pattern that my body responds to. I am going to calmly change this old habit. I feel some peace, despite my anxiety, and this peace is going to grow and grow. As my peace and security grow, then anxiety and panic will have to shrink. 3. At first, my anxiety was powerful and scary, but as time goes by it doesn’t have the hold on me that I once thought it had. I am moving forward gently all the time. 4. I don’t need to fight my feelings. I realize that these feelings won’t be allowed to stay around very much longer. I just accept my new feelings of peace, contentment, security, and confidence. 5. All these things that are happening to me seem overwhelming. But I’ve caught myself this time and I refuse to focus on these things. Instead, I’m going to talk slowly to myself, focus away from my problem, and continue with what I have to do. In this way, my anxiety will shrink and disappear. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 101 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities PERSONAL VALUES
Card Sort
IMPORTANT TO ME VERY IMPORTANT
TO ME NOT IMPORTANT TO
ME ACCEPTANCE
ACCURACY
to be accepted as I am
to be accurate in my opinions and
beliefs
W.R. Miller, J. C’de Baca, D.B.
Matthews, P.L.
Wilbourne
University of New Mexico, 2001
1 2 ACHIEVEMENT
ADVENTURE
to have important accomplishments
to have new and exciting experiences
3
4
ATTRACTIVENESS
AUTHORITY
to be physically attractive
to be in charge of and responsible
for others
5
6
Page 102 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities AUTONOMY
BEAUTY
to be self-determined and independent
to appreciate beauty around me
7
8 CARING
CHALLENGE
to take care of others
to take on difficult tasks and problems
9 10 CHANGE
COMFORT
to have a life full of change and variety
to have a pleasant and comfortable life
12 11 COMMITMENT
COMPASSION
to make enduring, meaningful
commitments
to feel and act on concern for others
13
14
CONTRIBUTION
COOPERATION
to make a lasting contribution
in the world
to work collaboratively with others
15
16
© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 103 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities COURTESY
CREATIVITY
to be considerate and polite
toward others
to have new and original ideas
17 18 DEPENDABILITY
DUTY
to be reliable and trustworthy
to carry out my duties and obligations
19 20 ECOLOGY
EXCITEMENT
to live in harmony with the environment
to have a life full of thrills and
stimulation
21 22 FAITHFULNESS
FAME
to be loyal and true in relationships
to be known and recognised
23
24
FAMILY
FITNESS
to have a happy, loving family
to be physically fit and strong
25
26
Page 104 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities FLEXIBILITY
FORGIVENESS
to adjust to new circumstances easily
to be forgiving of others
27 28 FRIENDSHIP
FUN
to have close, supportive friends
to play and have fun
29 30 GENEROSITY
GENUINENESS
to give what I have to others
to act in a manner that is
true to who I am
31 32
GOD’S WILL
GROWTH
to seek and obey the will of God
to keep changing and growing
33
34
HEALTH
HELPFULNESS
to be physically well and healthy
to be helpful to others
35
36
© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 105 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities HONESTY
HOPE
to be honest and truthful
to maintain a positive and
optimistic outlook
37 38
HUMILITY
HUMOUR
to be modest and unassuming
to see the humorous side of
myself and the world
39
40
INDEPENDENCE
INDUSTRY
to be free from dependence on others
to work hard and well at my life tasks
41
42
INTIMACY
INNER PEACE
to experience personal peace
to share my innermost experiences
with others
43
44
JUSTICE
KNOWLEDGE
to promote fair and equal treatment
for all
to learn and contribute valuable
knowledge
45
46
Page 106 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities LEISURE
LOVED
to take time to relax and enjoy
to be loved by those close to me
47
48
LOVING
MASTERY
to give love to others
to be competent in my everyday
activities
49
50
MINDFULNESS
MODERATION
to live conscious and mindful
of the present moment
to avoid excesses and find a
middle ground
52
51
MONOGAMY
NON-CONFORMITY
to have one close, loving relationship
to question and challenge authority
and norms
53
54
NURTURANCE
OPENNESS
to take care of and nurture others
to be open to new experiences,
ideas, and options
55
56
© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 107 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities PASSION
ORDER
to have deep feelings
about ideas,
to have a life that is well-ordered
and organised
activities, or people
58
57
PLEASURE
POPULARITY
to feel good
to be well-liked by many people
59
60
POWER
PURPOSE
to have control over others
to have meaning and direction in my life
62
61
RATIONALITY
REALISM
to be guided by reason and logic
to see and act realistically
and practically
63
64
RESPONSIBILITY
RISK
to make and carry out
responsible decisions
to take risks and chances
65
66
Page 108 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities ROMANCE
SAFETY
to have intense, exciting
love in my life
to be safe and secure
67
68
SELF-ACCEPTANCE
SELF-CONTROL
to accept myself as I am
to be disciplined in my own actions
69
70
SELF-ESTEEM
SELF-KNOWLEDGE
to feel good about myself
to have a deep and honest
understanding
of myself
72
71
SERVICE
SEXUALITY
to be of service to others
to have an active and satisfying sex life
73
74
SIMPLICITY
SOLITUDE
to live life simply, with minimal needs
to have time and space where I can
be apart from others
75
76
© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 109 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities SPIRITUALITY
STABILITY
to grow and mature spiritually
to have a life that stays fairly
consistent
78
77
TOLERANCE
TRADITION
to accept and respect those who
differ from me
to follow respected patterns of the past
80
79
VIRTUE
WEALTH
to live a morally pure and excellent life
to have plenty of money
81
82
WORLD PEACE
Other Value:
Other Value:
Other Value:
to work to promote peace in the world
83
Page 110 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 15: Ranking of Personal Values Card Sort Card Value eg. Card 1 43. Inner peace What iit m
means tto m
me Card 1 Card 2 Card 3 Card 4 Card 5 Card 6 Card 7 Card 8 Card 9 Card 10 Card 11 Card 12 Card 13 Card 14 Card 15 I’ve wanted this for so long, my life has been a real mess. If I had inner peace then it would mean that everything else must be in place. © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 111 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 16: Personal Values Exercise This exercise will help you to think through what areas of life are important to you. This means both your values as well as the things that you value. For each value take some time to identify how you would like to live the particular value and write it down on the second sheet. This can be a difficult exercise as it is easy to say that family is important, but it can be hard to articulate what that means to you personally. Values are life directions rather than goals. While goals can be achieved, values cannot. Values are the things we hold dear, close to our hearts. The things that are most important to us. So a value might be to be a more considerate partner and a goal may be to spend more time with my partner. 1. Relationships a. Family (other than partner or parenting): Describe what sort of brother, sister, son, daughter, etc that you would like to be. How would you ideally like to treat others in your family? b. Relationship/Intimacy: Think about the ideal relationship. What would your role be and how would it fit with that of your partner? c. Parenting: How would you want your children to describe you? Imagine they are talking about parenting as adults, what would you like them to have learnt from you? d. Friends/Social Life: How could you be a best friend? Do you know someone who you look up to in this way? What is it about them that you admire? 2. Work a. Workplace/career: What would be your ideal job? Not the name of the job but the type of work you would do and why it would be your ideal. What would you like your work relationships to be like? What sort of co‐worker would you want to be? b. Education/Training: What would you like to be studying, or what area of skills development is important to your future? 3. Personal growth/Health a. Think of someone who has grown through difficult times, what do you admire about them? What people in public life, sports people for example, do you admire, and why? b. Physical self‐care: How would you ideally look after yourself? What about this is important to you? Think about things like sleep, exercise, smoking, your appearance, health problems. c. Spirituality/religion: Is this important to you? How would you like to practice your spirituality/religion? 4. Leisure/fun and activity: What would your ideal weekend, holiday, day off, evening, look like if you were living life in recovery? Page 112 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Area Description 1. Relationships a. Family (other than partner or parenting) b. Relationship/Partner c. Parenting d. Friends/Social life 2. Work a. Workplace/career b. Education/Training 3. Personal Growth/Health a. Physical Self Care (diet, exercise, sleep) b. Spirituality/Religion 4. Leisure/fun & activity
© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 113 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 17: Values ‘Bull’s Eye’ YOUR VALUES: What really matters to you, deep in your heart? What do you want to do with your time on this planet? What sort of person do you want to be? What personal strengths or qualities do you want to develop? 1. Relationships: includes your partner, children, parents, relatives, friends, and other social contacts. 2. Work/Education: includes workplace, career, education, skills development, etc. 3. Personal Growth/Health: may include religion, spirituality, creativity, life skills, exercise, nutrition, and/or addressing health risk factors like smoking, alcohol, drugs or overeating etc 4. Leisure: how you play, relax, stimulate, or enjoy yourself; activities for rest, recreation, fun and creativity. THE BULL’S EYE: make an X in each area of the bull’s eye to represent where you stand today. “I am acting very inconsistently with my values” Work/Education
Relationships “I am living fully by my values” Leisure
Personal growth/Health Adapted with permission from © Russ Harris, 2007 (adapted from Tobias Lundgren’s "Bull’s Eye") www.actmindfully.com.au Page 114 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 18: Cultivating Positive Affirmations and Vision We can use the values in the chart to help guide us in our actions and decisions about how we might be leading our lives, and where we might like to be doing something different. This might be difficult in early recovery, and maybe you’re not used to thinking about your positive attributes. This exercise is designed to help you recognise some of these things, and to start to appreciate these qualities. As you continue in recovery the list will grow and change. Don’t worry if there are only one or two things written in each box. The values you record will help you guide your actions and your decisions about how you lead your life from this point on. Internal Values External Values Talents What you naturally do well, without thinking too much about it Knowledge Specialist knowledge Passions What lights me up, makes me shine Contacts The people I know Purpose What drives me and brings meaning to my life Character Unique things about me that I notice and others notice Adapted from Liana Taylor (2008); Adapted with permission from Hollon and Kendall (1980). © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 115 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 19: My Relapse Dangers The following are examples of situations which pose a danger to many people in recovery. Read through these and then write in the space below the situations that pose the greatest relapse danger to you at this time. These are the ones that you should avoid if at all possible. If you can’t avoid them, then accept the need to plan carefully and get as much support as you can. 1. Relapse Danger #1: Being bored and missing the action of partying and using. Steps I can take to handle this situation without using drugs: • Keep involved in NA meetings and activities so I can hook up with other clean people to learn what they are doing to cope with boredom. • Call my sponsor or other NA friends when my boredom starts me thinking about using. • Make a plan for every weekend because this is the time I feel most bored. My Relapse Danger #1: Steps I can take to handle this situation without using: 2. Relapse Danger #2: Feeling depressed about my life and how I messed it up. Steps I can take to handle this situation without using drugs: • Keep remembering that it will take time to get my life together after stopping using. • Focus on the positive things I have— family, partner, learning new skills and my improved health. • Talk about how I feel and get support from others in the program. My Relapse Danger #2: Steps I can take to handle this situation without using: Page 116 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Worksheet 20: Problem Solving 1. Identify and define the problem • Try to state the problem as clearly as possible; • Try to understand what maintains the problem, rather than just its cause; • Consider the different approaches you could use to solve the problem; • Select what you consider would be the most useful approach; • Assess its effectiveness; and • If needed, change the approach. The Problem: What maintains the problem: Possible approaches: 2. The best solution seems to be: 3. Assessment and review: © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2009 Page 117 Amphetamine‐Type Stimulants: Treatment Protocol for Therapeutic Communities Work sheet 21: Relapse Prevention Plan Early warning signs for relapse 1. 2. 3. 4. 5. 6.
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