Addiction Is Like Other Chronic Lifestyle-related Illnesses

June 26, 2014

Addiction Is Like Other Chronic Lifestyle-related Illnesses

By Terence T. Gorski, Author

People with heart disease strive to live a “heart-healthy” lifestyle to lower their relapse risk. Stabilizing the initial heart-attack is the beginning of changes in diet, exercise, stress-man agent, work, friendship, and family activities.

The same is true of chemical addiction. Once we have an addictive-life crises we need to strive to live a “sobriety/responsibility health” lifestyle. Detoxing and stabilizing from the initial addictive crisis is not enough. To avoid relapse we must learn a serious of skills that will help us to change in was that support meaningful and comfortable sobriety and provides effective tools and support for managing the stress and dysfunction that cab lead back into addictive use

 

 

 


The Progression of Addiction

June 14, 2014

An Excerpt from:
Straight Talk About Addiction
By Terence T. Gorski

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Addiction is not something that suddenly happens. It usually progresses just fast enough to start changing how you think, feel, act, and relate to other people; and just slow enough to make it difficult for you and others to notice the changes that are slowly developing into serious alcohol and drug related problems.

Straight Talk About Addiction
By Terence T. Gorski

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Moral Reasoning In Recovery

June 14, 2014

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By Terence .T. Gorski

Moral reasoning and developing higher levels of moral development is important to the addiction recovery process. Progressive recovery should be defined in part by developing improved moral reasoning skills. This is based upon the assumption that the recovery process should produce people who are more likely to make good decisions based on high levels if moral development and less likely to make bad decisions based upon lower levels of moral development.

The application of the principles of moral development to the recovery process is an area that needs more in-depth exploration. I mention it briefly in this blog to put the area of moral development in recovery on the table for future discussion.

Here are my initial assumptions:

Assumption: Low levels of moral development increase the risk of addiction. If this assumption is correct it could explain recent research indicating that:

– The use of addictive substances in childhood and adolescence increases the risk of substance abuse and addiction while
– Abstinence from the use of addictive substances during childhood and adolescence is related to significantly lower levels if abuse and addiction.

During childhood and adolescence levels of moral development are low because they have not yet been developed and integrated into personality and lifestyle processes.

The effects of the use of addictive substances can block on a biological level the emotional integration process needed for the development of conscience (the inner moral compass) and empathy (a sense if caring and sensitive reaction to the feelings of others and a caring response to the suffering if others).

Assumption #2: The progressive symptoms of addiction can impair judgment and impulse control as measured by the capacity for behavioral self-regulation. This can lead to a regression in moral development.

In treatment/recovery there is a big difference in the evidence of improved levels of moral development between:
– Individuals who had high levels of moral development that declined as a result of the progressive symptoms of adult onset addictive disorders; and
– Individuals who never developed age appropriate moral development skills because if child/adolescent onset addictive disorders.

Doing Good and Feeling Good

Sometimes it doesn’t feel good to do the right thing. Determining the right thing to do in specific situations can be challenging.

Many people define the recovery process as “learning how to do the next right thing and then doing it even if it doesn’t feel good in the moment.”

Knowing what the next right thing is requires:

– Accurate information about addiction, recovery, and relapse management;

– Skills in rational thinking, emotional management, impulse control, self-motivation, and basic communication, relationship and life skills;

– Intuitive awareness; and

– Making distinctions between what we feel and the results systematic moral reasoning.

These skills are often not specifically addressed in treatment/recovery.

The Distinction Between Right and Wrong

The foundation of moral reasoning must be based upon a clear distinction between right/good and wrong/bad. I suggest teaching basic moral reasoning using the following criteria.

The standard to evaluate the morally right/good is related to:

– Life,
– Health,
– Energy/Vitality,
– Abundance/Increasing access to resources, and
– Individual Freedom.

The standard for morally wrong/bad is related to the opposites of the morally right/good:

– Death,
– Illness,
– Lethargy/Depression,
– Deprivation/Lack of and decreasing access to resources, and
– Lack of freedom.

The following open ended questions can be used in making basic moral judgments.

1. To what degree does the proposed action lead to the protection of human life, as opposed to increasing the risk of death? (0 – 10).

Note: Progressive addiction leads to high risk of endangering human life through accidents and illness.

2. To what degree does the proposed action contribute to developing greater levels of health, as opposed to the symptoms of illness? (0 – 10)

Note: Progressive addiction leads to declining health and progressively more severe symptoms of illness.

3. To what degree does the proposed action contribute to a increasing feelings of energy/vitality (as opposed to lethargy/depression).

Note: Progressive addiction leads to a declining sense of energy and vitality and progressively more severe feelings of lethargy and depression.

4. To what degree does the proposed action contribute to an increasing access to resources related to making valuable contributions to others.

Note: Progressive addiction leads to progressive inability to gain access to resources because if the progressive irresponsibility related to progressive addiction.

4. To what degree does the proposed action contribute to an increase in personal freedom, as opposed to reduced levels of freedom.

Note: Progressive addiction leads to loss if freedom caused by:
– The progressive enslavement to the addiction caused by the progressive pattern of compulsive use (loss of control) that consumes more time, energy, and resources as the addiction progresses; and
– Restrictions on personal freedom imposed by other people and society as a protection against the progressive dangerous and destructive consequences of addictive use.

Sometimes doing good doesn’t feel good (i.e. Doing what is morally right doesn’t always produce pleasant feelings).

Resources:

Early Childhood Moral Development: http://www.bhcmhmr.org/poc/view_doc.php?type=doc&id=12769&cn=462

Kohlberg’s Stages of Moral Development:
1. http://faculty.plts.edu/gpence/html/kohlberg.htm
2. http://psychology.about.com/od/developmentalpsychology/a/kohlberg.htm
3. http://en.m.wikipedia.org/wiki/Moral_Development


Adolescent Relapse Prevention

June 13, 2014

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By Terence T. Gorski, Author of
The Adolescent Relapse Prevention Workbook

This article describes the differences between adolescent and adult substance abusers that can lead to relapse and presents practical suggestions for matching the unique needs of adolescent substance abusers to relapse prevention strategies in order to decrease the rate of relapse.

Adolescent chemically dependent patients relapse at a much higher rate than adults. Studies[1] indicate that approximately 42% of adolescents who complete inpatient treatment for chemical dependence maintain total abstinence from alcohol or other drugs during the year following treatment. This is much lower than the 66% abstinence rate reported for adult inpatient programs with similar treatment philosophy and geographic locations.

Seventy-eight per cent of adolescents who relapse (45% of all adolescents treated) do so during the first six months of recovery. The good news is that 77% of those who made it through the first six months of recovery without relapsing maintained their abstinence for the entire year. Of the patients who relapsed during the first six months, 28% were abstinent for the second six months. Of those adolescents who relapse (58% of all adolescents treated), approximately 40% (23% of all adolescents treated) have short-term and low consequence relapses and rapidly return to sobriety. The other 60% (34% of the population) have long-term, high consequence relapses.

Reasons For Adolescent Relapse

There are significant differences between adult and adolescent chemical addictions and the failure to recognize these differences can be an important contributor to adolescent relapse.[2] Most chemically dependent adolescents have three coexisting problems that increase relapse risk:

(1) Chemical Addictions (Adolescent Substance use Disorders)

(2) Normal Problems With Adolescent Development, and

(3) Adolescent Mental Disorders.

Adolescent Substance Disorders

Many chemically dependent adolescents relapse because they fail to recognize that they are chemically dependent and need to abstain from alcohol and drugs. This is especially true for adolescents who are in the early stages of their addiction or lack a long history of alcohol and drug related problems.

Forcing early stage adolescents into harshly confrontational inpatient programs against their will can create high relapse rates after discharge. Many of these adolescents go into compliance and passively resist treatment and, although on the surface many appear to be model patients, after discharge they rapidly return to alcohol and drug use because they have failed to recognize and accept their addiction.

Recovery rates can be improved by using outpatient motivational counseling techniques and substituting intensive outpatient treatment for inpatient treatment.

Some adolescent programs focus exclusively upon the chemical addiction while minimizing or ignoring problems with normal adolescent development or adolescent disorders which can lead to relapse. Many adolescent programs, for example, set behavioral standards that would be appropriate for adults but are inappropriate for adolescents in certain stages of development.

Since the onset of chemical addiction causes many adolescents to stop normal emotional development, treatment centers can overcome this problem by assessing the stage of adolescent development and setting appropriate behavioral expectations and treatment goals.

Normal Problems With Adolescent Development

It can be easy to forget that adolescent substance abusers are children who are not capable of functioning up many adult standards. Normal adolescence is a difficult period of adjustment. Hormones go on-line and start to rage. Social relationships become more complicated. Pressure from peers to conform and pressure from parents and teachers to excel can weigh heavily on many if not most teenagers.

Effective adolescent treatment programs take the stage of adolescent development into account and design treatment plans that are appropriate to the adolescent’s current developmental level. Failure to do so can significantly increase the risk of relapse.

Adding educational approaches to the recovery and relapse prevention process can go a long way to preventing relapse for adolescents in the school environment. [4]

Coexisting Psychosocial Problems

Typical chemically dependent adolescents have three major life problems in addition to their chemical addiction to contend with when they enter treatment.[3] The most common problems include school problems (58%), dysfunctional relationships with one or both parents (38%), parental substance abuse (35%), physical abuse (30%), sexual abuse (37% of females and 5% of males), depression (29%), and suicide attempts (16%). If left untreated, these other problems can create ongoing pain and dysfunction which lead to relapse.

While treating these other problems, however, it is important to keep an addiction focus. To treat these other problems without helping the adolescent to recognize the role that their alcohol and drug dependence has in creating and maintaining these problems can also contribute to relapse.

An effective relapse prevention approach is to provide balanced treatment for adolescents that focuses upon diagnosing and treating their chemical addiction, the normal tasks of adolescent development that they need to cope with in sobriety, and other major life problems that can jeopardize sobriety.

Selecting The Appropriate Treatment Setting

It is important that adolescents be matched to an appropriate treatment setting. There is the mistaken belief that the preferred treatment setting for all adolescents is a long-term inpatient treatment environment.

Many adolescents, especially those in the earlier stage of addiction with less severe coexisting problems and supportive families, do better in outpatient environments where they can maintain their academic and family lives than in long-term inpatient programs that disrupt the normal course of their lives. For adolescents with late stage chemical addiction with numerous severe, coexisting problems and little or no family support, inpatient treatment may be necessary.

The Role Of Outpatient Treatment In Relapse Prevention

Ongoing outpatient treatment is vitally important in preventing adolescent relapse. The majority of adolescents relapse in the first six months with the second highest risk period being the second six months. Adolescents who are not involved in outpatient treatment that includes family involvement for at least one year following discharge from inpatient are at high risk of relapse.

Failure To Teach Warning Sign Identification & Management

The final factor that contributes to an increased relapse rate among adolescents is the failure of many treatment centers to teach the adolescent patients and their families how to identify and manage relapse warning signs.

Relapse is a process that begins long before adolescents begin drinking and drugging again. There are progressive and predictable warning signs that indicate that the adolescent is getting into trouble with his or her recovery.

The typical sequence of warning signs normally begins when a situational problem triggers the adolescent to react with old addictive ways of thinking. The addictive thinking creates painful and unmanageable feelings. In order to cope with these feelings, the adolescents begin reverting to alcohol and drug seeking behaviors which put them back in contact with other adolescents who are drinking or drugging. Once in this environment, return to use is inevitable.

Teaching adolescents and their families to recognize and intervene upon the early warning signs can prevent unnecessary relapse. Helping the adolescent, the family members, and other concerned persons to intervene as soon as addictive use begins can help assure that adolescents will experience short-term and low consequence relapses.

References

[1] Harrison, P.A. and Hoffmann, N. G. (1989), CATOR Report: Adolescent Treatment Completers One Year Later, Ramsey Clinic, St. Paul, MN, pp. 47-48.

[2] Bell, Tammy, Preventing Adolescent Relapse – A Guide For Parents, Teachers And Counselors, Herald House/Independence Press, Independence, Missouri, 1990

Treatment Completers One Year Later, Ramsey Clinic, St. Paul, Minnesota, p. 40.

[3] Harrison, P.A. and Hoffmann, N. G. (1989), CATOR Report: Adolescent

[4] Adding Education to the Relapse Prevention Model: http://www.addictionpro.com/article/adding-education-model 

The Adolescent Relapse Prevention Workbook

About the Author

Terence T. Gorski is internationally recognized for his contributions to Relapse Prevention Therapy. The scope of his work, however, extends far beyond this. A skilled cognitive behavioral therapist with extensive training in experiential therapies, Gorski has broad-based experience and expertise in the chemical dependency, behavioral health, and criminal justice fields.

To make his ideas and methods more available, Gorski opened The CENAPS Corporation, a private training and consultation firm of founded in 1982. CENAPS is committed to providing the most advanced training and consultation in the chemical dependency and behavioral health fields.

Gorski has also developed skills training workshops and a series of low-cost book, workbooks, pamphlets, audio and videotapes. He also works with a team of trainers and consultants who can assist individuals and programs to utilize his ideas and methods.

Terry Gorski is available for personal and program consultation, lecturing, and clinical skills training workshops. He also routinely schedules workshops, executive briefings, and personal growth experiences for clinicians, program managers, and policymakers.

Mr. Gorski holds a B.A. degree in psychology and sociology from Northeastern Illinois University and an M.A. degree from Webster’s College in St. Louis, Missouri. He is a Senior Certified Addiction Counselor In Illinois. He is a prolific author who has published numerous books, pamphlets and articles. Mr. Gorski routinely makes himself available for interviews, public presentations, and consultant. He has presented lectures and conducted workshops in the U.S., Canada, and Europe.

The Adolescent Relapse Prevention Workbook


Managing Grief and Loss In Recovery

June 13, 2014

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By Terence T. Gorski, Author

If you lose someone you love and you don’t miss them there is something seriously wrong. Grief from the loss of a loved one is a normal part of life. People recovering from addiction need to learn how to cope with the loss Ina sober and responsible way. Mismanaging grief and loss lead to depression and activate the relapse process. (see Depression and Relapse).

I find the loss of a loved one is a strange thing. The better the relationship we had with someone we lose, the more it hurts to lose them. The pain never goes away because there remains a hole in our soul — an emptiness that cannot be filled by anyone else.

Anniversaries of a loss are tough. At best they are bitter-sweet. I find, however, that dealing with loss is a skill that can be learned — must be learned — if we want to mature as a human beings.

The stages of mourning and grief are universal and are experienced by people from all walks of life. Learning about the steps and stages of managing grief and loss can help us accept the process as normal and natural and develop skills for managing the different steps of the process. It still hurts, but the pain is more easily managed when we know we are not crazy for experiences.

Each of us must find our own way to cope with grief and loss. Their is no right or wrong way to do it and no universal time-frame for resolving it.

There is, however, a model that helps many people understand and accept the process. A five stage model of normal grief was first proposed by Elisabeth Kübler-Ross in her 1969 book “On Death and Dying.” I’m reality, however, the process is not as orderly or predictable as the five stages of grief make it seem.

I summarize the stages of grief with the acronym DABDA:

D = Denial. This can’t be happening!

A = Anger, usually at life and/or at God. “They can’t take you! You can’t leave me. You have no right to do this to me! What kind of a god would let this happen?”

B = Bargaining. I’ll do anything, pay any price, negotiate any deal to avoid losing this person.

D = Depression. There is a deep sense if traumatic loss that is biopsychosocial. Biologically there are brain chemistry crashes. Psychologically we feel empty and incomplete. Socially there is a big hole in the fabric of our lives.

A = Acceptance. We adapt to the loss, but acceptance does not mean we go back to feeling the way we did before the loss. The loss changes us and we learn to adapt to a new normal as we rebuild our lives.

The stages of grief model suggests people move through grief and get done with the process. In my experience that is not the case. Most people bounce from stage to stage and cues or triggers such as anniversaries and holidays can snap us back into the grief process.

I find that loss is easier to handle if I focus on the good memories and good things and consciously connect with gratitude for having those times with that special person. The only alternative is to stay in anger and forget the gifts this person gave us. This can leave us bitter.

In sobriety we learn to cope with the bitter taste of the loss while savoring the good things that we gained. And we must learn to do it in a sober and responsible way. That means feeling what we feel and developing deeper relationships with other people to help us through the process.

Using alcohol or other drugs to cope with the loss makes things more difficult and painful. It leads to a loss of control of our addiction and hitting a new bottom. When we get back in recovery the unresolved grief is waiting for us. It can complicate our new efforts at recovery and contribute to unnecessary relapse.

The good news is that we can learn to deal with grief and loss in a sober and responsible way. Cognitive Restructuring can help us when the skills are specifically applied to the process of managing grief and loss.

GORSKI BOOKS: www.relapse.org


Evidence-based Practice: An Elusive Ideal

June 13, 2014

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There is a strong movement toward evidence-based practice and a new buzz-word, evidence-based leadership. is becoming popular. The evidence-based movement involves the complex process of:

1. Figuring out what treatment practices have positive effects on treatment outcomes;

2. Encouraging professionals to use evidence-based principles and practices by encouragingly the use of continuous quality improvement;

3. Promoting a culture of creativity, growth and change within a consistent structure while avoiding cumbersome regulations that fail to add value to the process of patient care.

Evidence-based practice is becoming very complex stuff which, unfortunately, is placing many more levels of complexity between leadership and patient care. The following article reflects, in my opinion, why the evidenced-based movement is struggling.

– The idea of evidence-based practice is becoming way to complex.

– The evidence for what works and what doesn’t work is very weak.

– Different professional cultures fail to effectively communicate and collaborate.

There is the misconception that we know what works and need to force regulations into place that add little or no value to clinical practice.

The comes ideas of evidence-based practice is replacing the idea of simple applied research systems processes once called continuous quality improvement.

It might be helpful to ask both professionals and patients to describe in plain English what they found to be helpful and not helpful in their experience of the treatment process.

For better or worse, here is a description of the complexities of the evidence-based treatment. In my opinion the ideas are far too complex to be practically implemented and the “evidence-based ideal” is placing additional levels of complexity between leadership and patient-care.

The challenge is to simplify the process for real-world application. I still prefer the idea of continuous quality improvement based upon systematic measurement of concrete outcomes close to the the level of patient care that involves patient self-measurement, clinical professional measurement of the same factors, and administrative measurement of treatment plan implementation and incident reporting. The system has been implemented and validated in addiction and mental health programs and requires limited investment.

The USA government has developed and field-tested proven methods for implement CQI in addiction and mental health programs.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2483604/pdf/v007p00149.pdf

Cognitive Restructuring for Addiction is an evidence-based practice that can be implemented in the real world and its effectiveness monitored with CQI methods in a cost effective way. Simple measurement of the patients ability to use the five core cognitive restructuring skills (Thought Management, Feeling Management, Urge/Motivational/Craving Management, Behavioral Recovery Skill Acquisition, and Relationship management. It is a skill based model and the ability of recovery people to learn and use the skills can be measured. Knowing how to use the skills, however, is no guarantee they will be used consistently in recovery. These skills also lend themselves to self-monitoring, an evidence-based cognitive-behavioral therapy technique shown to enhance positive change.

References for Continuous Quality Improvement (CQI)

Deming, W. E. (2000). Out of the crisis. Cambridge, MA: MIT Press.

Gustafson, D., & Hundt, A. (1995). Findings of innovation research applied to quality management principles for health care. Health Care Manager Review, 20(2), 16–33.

Langley, G. L., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). San Francisco, CA: Jossey-Bass. NIATx. (2008). CQI model. Retrieved August 26, 2009, from http://www.niatx.net

GORSKI BOOKS: www.relapse.org

Cognitive Restructuring for Addiction


Using Cognitive Restructuring for Addiction (CRFA) 

June 11, 2014

CENAPS_CRFA_ArrowBy Terence T. Gorski, Author
The Cognitive Restructuring for Addiction Workbook 

There is a simple formula for applying cognitive restructuring principles to nearly any problem. Here is how it works:
Write down both a title and a description for the problem. Here’s an example:
Title: Frustrated With My Job
Description: I know that I am in trouble with my recovery when I keep getting upset by little frustrations at work that I can usually handle well.
NOTE: Don’t use the exact same words in the title as in the description. Using different words forces your brain/mind to understand the problem on different level and from  different point of view. 
Start the TFUAR Analysis by completing the following statements: 
T = Thinking: When I am experiencing this problem I tend to think …
F = Feeling: When I am experiencing this problem I tend to feel …
U = Urges (Motivations): When I am thinking and feeling this way I tend to have the self-defeating urge to …
A = Action: When I experience that self-defeating rugs what I actually do that usually fails to solve the problem is …
R = Reactions: When I take this action other people tend to react to me in ways that make the problem worse by …
Complete the TFUAR Analysis Process by answering the following questions: 
T = Thinking:  What is another way of thinking that could help me approach this problem in a more effective wash?
F = Feeling: If I were to start thinking that way how would it change what I was feeling? Would that change in feeling help me approach this problem in a more effective wash?
U = Urges (Motivations): if my feelings changed in that way, how would my urges (motivations) to act out my old self-defeating behaviors change?
A = Actions: If my urges/motivations changed in that way, what new actions could I take that would help me to deal with this problem in a  more effective way?
R = Reactions: If I used the new actions, how would the reactions of others be likely to change in a way that would help me approach the problem in a more effective way?
By using this process of TFUAR Analysis over and over again every time you experience a problem, you will begin to develop new and more effective habits for dealing with problems.
For more I information on using cognitive restructuring in your life get The Cognitive Restructuring for Addiction Workbook and use it as the basis of a discussion group with other people you know who are committed to personal growth and development.

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