Black or White Thinking

January 14, 2015

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By Terence T. Gorski
Author (The Books of Terence T. Gorski)

Black and white thinking, also known as all-or-nothing thinking, is the failure to bring together both positive and negative qualities of the self, other people, and the world into a cohesive and realistic whole.

It is a common defense mechanism used by many people that allows them to lock onto one aspect of things while blocking out others. This can make the world appear more manageable and comprehensible.

In reality, apparent opposites often live together in the real real world. Here are some examples.

The world is both …
– Good and evil;
– Loving and cruel;
– Safe and dangerous;
– Understandable and incomprehensible.

In reality, it is all of these things and much more all at the same time. What we see depends upon where we look and what point of view we choose to take.

Never underestimate our ability to lock onto to some things and block out other things based upon our belief in the truth.

It provides great comfort to shrink the world into something small and manageable. This can work in times of great stability. During times of great and radical change it is important to be able to view reality as it is, not as we would like it to be.

Read more about how black and white thinking can hurt us and what we can do about it.

Learn more about Cognitive Restructuring for Addiction. This is practical workbook and guide making cognitive restructuring tools readily available to both therapists and recovering people.

The Books of Terence T. Gorski)


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.

Cognitive Restructuring: Why It Works With Addiction

June 8, 2014

Addictive ThinkingBy Terence T. GorskiAuthor

Abstract: This detailed blog by Terence T. Gorski explains the biopsychosocial factors in chemical and behavioral addictions; describes how cognitive restructuring can change addictive thoughts, feelings, and behaviors; and shows how the process can provide organization to the treatment/recovery process while improving the collaboration between the addiction professional and the recovering person. References are provided that show that Cognitive Behavioral Therapy (CBT), the core method upon which Cognitive Restructuring for Addiction is based, is an evidence-based practice.

COGNITIVE means information processing in the brain.

RESTRUCTURING means changing how information is processed by the brain.

ADDICTION, described in DSM IV as Substance Use disorders), is described in DSM 5 as addictive disorders and has been expanded to include: Chemical Addictions (alcohol and other mind altering drugs of abuse); and Behavioral Addictions (gambling and other forms of compulsive mood altering behaviors).

All addictive disorders share a common set of similarities which include:

  • Addictive Beliefs (Addictive use is an effective way to stop my pain and solve my problems);
  • Automatic repetitive addictive thinking patterns (often called addictive rumination) that is difficult to self-regulate;
  • Obsession (Out-of-control thinking about the addiction);
  • Compulsion (the strong irrational urge to engage in addiction seeking behavior and addictive use);
  • Craving (A powerful urge based in a psychobiological response to cues or triggers that activates a powerful urge ton use in order to normalize the uncomfortable feelings caused by the biological symptoms of the craving);
  • Loss of Control (A pattern of compulsive use making it difficult self regulate the quantity, frequency, or duration of addictive use episodes);
  • Secondary life and health problems caused by the loss of control. These tend to be related to the specific addictive release being used); and
  • Continuation of use in spite of adverse consequences and a subjective desire to stop and reduce the use.

Each specific addictive disorder that is organized around a specific drug of choice or behavior of choice has unique differences that need to be considered in treatment. An alcoholic who does not use prescription or illicit drugs will participate in a different addictive culture and have adaptations in their addictive thinking that accommodates the focus of their addiction. The same is true of Prescription drug Addicts who don;t use illicit drugs, illegal drug users also involved in criminal drug-centered culture, gamblers, compulsive over-eaters, etc.

As a result, the above symptoms of addiction are caused by:

  • A complex individualized (idiosyncratic) biopsychosocial responses in each addicted person;
  • The specific substance or behavior that is the primary source of addictive release;
  • The social and cultural reaction to the use, abuse, and addiction to the specific substance or behavior.
  • The degree of addictive brain dysfunction;  and
  • The unique information processing style of the  addict originating in the family of origin and influenced by social and cultural experiences.

These differences, however, are accompanied by a cognitive or information processing styles that are similar in all addicted people and create:

  • Addictive Beliefs/Automatic Thinking based upon the mistaken belief that “addictive use will take away my pain and solve my problems!”
  • Craving which is a strong irrational urge to use addictively in spite of good reasons not to. Cravings usually do not result from rational decision-making. They are usually activated by environmental cues or triggers. and
  • Habitual addiction-seeking behaviors, activated by the cue/trigger and acted out automatically and unconsciously. These addiction seeking behaviors are known as early relapse warning signs. Acting them out puts addicts into high-risk situations that surround then with people, places, and things that will encourage and support their use of alcohol and other drugs.

Cognitive restructuring is a proven method for:

1. Stopping addictive thinking and challenging addictive beliefs;

2. Managing craving;

3. Stopping or redirecting addiction-seeking behaviors;

4. Avoiding or effectively managing high risk situations;

5. Having a well-rehearsed emergency plan to stop addictive use should it begin; and

6. Using a debriefing process (sometimes called a relapse autopsy) to examine past relapse episodes and near-miss experiences in order to learn how to avoid or effectively manage similar situations in the future.

Cognitive restructuring for addiction, which is at the core of Relapse Prevention Therapy (RPT) is a core set of principles, practices, tools, and skills that can be used to enhance recovery and prevent relapse. When used effectively these principles and practices teach people:

  • How to change their thoughts, feelings, and behaviors in ways that eliminate or reduce craving and drug seeking behavior.
  • How to manage high risk situations;
  • How to find a sense of meaning and purpose in recovery that is note satisfying than acting out an addictive lifestyle.

The Cognitive Restructuring for Addiction Workbook contains a series of clear, simple, and effective exercises that can enhance recovery while breaking the cycle of relapse.

The exercises in the workbook can be applied to a wide variety of chemical and behavioural addictions as well as other problems involving the repetitive and habitual use of a specific self-defeating behavior.

The underlying cognitive restructuring process is the same. Additional information that is specific to unique addictive behaviors can increase effectiveness. The manual is based upon evidenced-based Cognitive Behavioral Therapy (CBT) principles and practices that are effective with addiction, depression, PTSD, and a wide variety of other disorders that are lifestyle-related and subject to periodic regression or relapse. (CBT and related therapies are documented as evidence-based practices by SAMHSA-NREPP.

A small investment in this inexpensive workbook can:

  • Organize and structure the recovery/therapy process;
  • Provide home-work assignments that increase progress; and
  • Demonstrate the use of evidence-based practices.

Most importantly, the proper use of the exercises in this workbook can literally make the difference between helping people to move forward in recovery, or to slide backwards into addictive use and the horrible damage than can be caused.

Click here to order: THE COGNITIVE RESTRUCTURING FOR ADDICTION WORKBOOK. This small investment could save you sobriety.

A Home Study that awards CEU’s for studying this workbook are available: email: tresa@cenaps.com or visit Gorski-CENAPS Home Studies 

 


Relapse Prevention: The Difference Between Counseling and Therapy

May 13, 2014

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The GORSKI-CENAPS® Model is designed to be used on two levels: the counseling level and the psychotherapy level. Let’s look at the distinction between those two levels.

1. The Counseling Level: Patients need to learn new ways of thinking and acting that will allow them to manage high-risk situations and other problems that occur in their lives without using alcohol or drugs. The primary focus is to teach the client how to do something different when they encounter these situations. Patients are taught to identify and more effectively manage the thoughts and feelings that get in the way of learning new and more effective ways of dealing with problem situations. This level is described in The Relapse Prevention Counseling (RPC) Workbook.

2. The Psychotherapy Level: These situations are created by repetitive self-defeating behaviors that are motivated by core personality and lifestyle problems. These basic mistaken beliefs about self, others, and the world motivate clients to become involved in and mismanage high-risk situations in spite of their conscious intent not to. This level is described in The Relapse Prevention a Therapy Workbook (RPT).

Core personality problems are self-defeating habits of thinking, feeling, acting, and relating to others.

Core lifestyle problems are the habitual ways of living and the agreements and relationships that we establish with other people at work, in the community, with friends, family, and lovers. These core lifestyle problems are a social structure that both supports and justifies the personality problems.

There are two different types of treatment designed to address these two different levels of client problems.

1. Counseling: Counseling is the process of teaching clients how to identify and manage high-risk situations and to identify and change the patterns of thinking, feeling, and acting that prevent them from effectively managing the situation. This is called Relapse Prevention Counseling.

2. Psychotherapy: Psychotherapy is the process of teaching clients how to identify and manage the core personality and lifestyle problems that cause them to keep putting themselves in high risk situations. It then teaches them how to identify and change the core belief systems and unconscious life rules that create and maintain their personality and lifestyle. This is called Relapse Prevention Therapy.

The GORSKI-CENAPS® Model has components that can address both levels of problems, but it is recommended that clinicians working at the psychotherapy level have a background in both addiction counseling and advanced clinical training in psychotherapy.

The following general decision rules are applied for determining when to work at the counseling or psychotherapy level. Before moving to the psychotherapy level:

1. Clients must be able to stay abstinent from alcohol and drugs before they can successfully work on psychotherapy issues.

2. Clients should be able to identify and manage high-risk situations at a counseling level without using alcohol or drugs before moving into Psychotherapy.

3. Clients need to have some skills at managing stress in a sober and responsible way. Focusing treatment upon core personality and lifestyle issues can defocus clients from identifying and managing high-risk situations that can cause alcohol and drug use. As a result, a premature focus upon psychotherapy can increase the risk of relapse.

4. Working on the psychotherapy issues can also increase pain and stress. This makes it even more difficult for the client to manage the high-risk situation.

5. Every high-risk situation is like the tip of an iceberg. It sits on top of a cluster of underlying personality and lifestyle problems. These underlying problems are often surfaced when the client starts learning how to identify and manage the high-risk situation.

6. It is often difficult to keep the client focused upon learning how to manage the high-risk situation when these deeper issues get activated. The client wants to focus upon the deeper issue because it is easier to look at psychotherapy issues than to focus upon learning basic abstinence skills. Since these issues are real and cause the client pain and discomfort, the counselor often feels obligated to work on these issues

7. It is inappropriate to ignore core personality and lifestyle issues or communicate to the client that these issues are not important. The client will have to resolve these issues if they are to learn how to maintain long-term abstinence. The issue is, there are other immediate situations that represent an immediate risk to abstinence. These issues must be dealt with first. Later we will review a technique called Bookmarking that will allow us to honor core personality and lifestyle issues as they come while keeping the primary focus upon identifying and managing the high-risk situations that can cause alcohol and drug use.

GORSKI BOOKS: www.relapse.org

LIVE SOBER – BE RESPONSIBLE – LIVE FREE


The Magic Triangle Relaxation Method

May 8, 2014

Magic Circle Relaxation 01by Terence T. Gorski, Author

Developed By Terence T. Gorski for use in Relapse Prevention Therapy (RPT) in 1995

Most relapse prone people have serious problems with stress that can lead to relapse. It is important to teach relaxation techniques that can be used to turn off or significantly reduce the immediate stress response when it occurs. Mindfulness mediation has become a popular evidence-based relaxation method, but there are other relaxation techniques that are also effective.

The Smorgasbord Approach To Relaxation Training

Relaxation training has been consistently integrated into the CENAPS® Model of Relapse Prevention since about 1985. Another blog with cover the seven core approaches to relaxation training and meditation used Certified Relapse Prevention Specialist (CRPS) and found to be helpful in their work.

The Magic Triangle Relaxation Technique is one specific application that integrates one application that has been used in the Relapse Prevention Certification School for many decades. It is not the only method that works, it is one of the methods.

Patients seem to do better when given a choice of relaxation techniques, and opportunity to experiment with the different core techniques, and the ability to choose what work best for them. Many Relapse Prevention Specialists have found that they can easily develop a personal relaxation exercise by combining the core approaches in a personalize script.

The Magic Triangle Relaxation Technique is one of the best techniques for teaching immediate relaxation response training because it involves a combination of deep breathing, guided imagery, and autosuggestion. The technique is called the Magic Triangle Relaxation Technique because it uses the focal image of a triangle to induce relaxation.

Self-Monitoring of Effectiveness

Self-monitoring is an evidence-based practice that is based upon the principle that regular self-evaluation of the effectiveness of a therapy technique tends to increase it’s effectiveness. Cognitive behavior therapists have found that using a simple subjective ten-point scale increases the effectiveness of self-monitoring.

The Stress Thermometer is simple stress scale for measuring the intensity of stress from patients on a self-report basis. The scale ranges from 1 -10 and allows easy measurement of four levels of stress:

  • Incapacitating Stress (Level 10),
  • High stress (Level 7-9),
  • Moderate stress (3-5) and
  • Low stress (1-3)

Before beginning and the end of each relaxation session ask the patient self-evaluate their current level of stress. At the end of the session, the therapist and patient compare the two scores and discuss which part of the relaxation training was most helpful. By keeping track of the scores and the technique used across sessions, patients can more accurately evaluate what works best for them as individuals. If patients do not perceive their stress level is decreased by the relaxation technique they are using, or if the technique actually raised their perceived stress, they rapidly lose the motivation build relaxation training into their recovery and healthy lifestyle plan.

The Magic Triangle Technique

Here is a detailed description of how to use the technique.

  1. Give a General Relaxation suggestion

“Take a deep breath and sit back in your chair. I am going to teach you an immediate relaxation response exercise called the Magic Triangle Relaxation Technique. Once you learn it, you will be able to use this technique to help you to turn off or significantly reduce stress whenever you become tense or agitated.”

  1. Give the Suggestion of Total Control and Safety

“You will be in total control of this relaxation process. If at any time you feel uncomfortable or frightened, all you need to do is to open your eyes, sit up, and look around the room and you will come back to the present.”

  1. Change Your Body Posture

“Change your body posture in the chair. Sit up straight, put your feet flat on the floor and look straight ahead. Find a spot on the wall or a spot in space in front of you. You can allow your eyes to close if it is comfortable, but you can also leave your eyes open and stare blankly in front of you as you let your mind relax and wander. You can do what feels best for you to do.”

  1. Body-awareness and Relaxation

“Notice your feet. Notice the pressure of your feet on the floor. Notice the feeling in your feet. Now say to yourself: ‘My feet are warm and comfortable. I feel a tingling sense of relaxation in my feet.’” (Repeat this suggestion three to five times)

“Now notice your legs. Notice the feelings in your lower and upper legs. Now say to yourself: ‘My legs are warm and comfortable. I feel a tingling sense of relaxation in my legs.’” (Repeat this suggestion three to five times)

“Now notice your lower body. Notice the feelings in your buttocks, lower back, and lower stomach. Feel the weight of your body pressing into your chair. As you are feeling the weight of your body say to yourself: ‘My lower body is warm and comfortable. I feel a tingling sense of relaxation in my lower body.’” (Repeat this suggestion three to five times)

“Now notice your upper body. Notice the feelings in your chest and upper back. Feel the weight of your body pressing into your chair. As you are feeling the weight of your body say to yourself: ‘My upper body is warm and comfortable. I feel a tingling sense of relaxation in my upper body.’” (Repeat this suggestion three to five times)

“Now notice your arms and shoulders. Notice the feelings in your arms and shoulders. Feel the weight of your arms as they rest comfortably on your lap. Notice the feeling of your arms gently pulling down on your shoulders. Notice any tension in your arms and shoulders and, if it is comfortable to do so, adjust your arms and shoulders to release the tension and become more relaxed.”

“As you are feeling the feelings in your arms and shoulders, say to yourself: ‘My arms and shoulders are warm and comfortable. I feel a tingling sense of relaxation in my arms and shoulders.’” (Repeat this suggestion three to five times)

“Now notice your neck. Notice the feelings in your neck. Notice any tension in your neck and, if it is comfortable to do so, adjust your neck by rotating it gently to release the tension and become more relaxed.”

“As you are feeling the feelings in your neck, say to yourself: ‘My neck is warm and comfortable. I feel a tingling sense of relaxation in my neck.’” (Repeat this suggestion three to five times)

“Now notice your head and scalp. Notice the feelings in your head and scalp. Imaging your scalp tingling with a warm sense of relaxation.”

“As you are feeling the feelings in your head and scalp, say to yourself: ‘My head
and scalp is warm and comfortable. I feel a tingling sense of relaxation in my head and scalp.’” (Repeat this suggestion three to five times)

“Notice your face. Notice any tension in your face. Notice your jaw and allow it to relax. Feel how heavy your jaw is becoming and allow your jaw to relax. If it is comfortable to do so, adjust your jaw by rotating it gently to release the tension and become more relaxed. Notice the feelings around your eyes. If it is comfortable to do so, move the muscles around your eyes to release any tension.”

“As you are experiencing the feelings in your face, jaws, and eyes, say to yourself: ‘My face, jaws, and eyes are warm and comfortable. I feel a tingling sense of relaxation in my face, jaws, and eyes.’” (Repeat this suggestion three to five times)

  1. Deep Breathing

“Notice your breathing. Notice how your breath flows in and out of your body. Notice that you can regulate how quickly or slowly you breath. Take a deep breath, hold it for a moment until your lungs feel tense, then slowly exhale. Take another deep breath, hold it for a moment until your lungs feel tense, then slowly exhale. One more time. Take another deep breath, hold it for a moment, slowly exhale.”

“Notice if you are breathing from high in your chest or low in the stomach. As you notice your breathing, lower the breathing deep into your stomach. Imagine your lower stomach going in and out with each breath you take.”

  1. Rhythmic Breathing

“Now, as you are listening to my voice and noticing yourself relax, slowly breath in to the count of four and out to the count of four. As you breath in allow your breathing to fill the lower part of your stomach. As you breath out feel the lower part of your stomach relax. Inhale … one, two, three, four .— exhale … one, two, three, four …hold it a moment.” (Repeat this for five to ten breaths)

  1. Visualizing the Triangle and Ball

“Now, visualize a black background before your eyes. See a bright red triangle, pointing up, with equal sides appearing on this deep black background. See the deepness of the red color within the triangle.”

“Now imagine a bright yellow ball at the bottom right hand side of the triangle. Imagine the ball rolling slowly up to the top of the triangle as you count slowly to four. Bring the ball up … one, two, three, four. Balance the ball at the top of the triangle. Bring the ball down … one, two, three, four.” (Practice this five to ten times).

  1. Combining Breathing and the Triangle and Ball

“Now, as you see the ball rising to the top of the triangle take a very slow and deep breath. As your lungs fill with air, imagine the ball balancing at the top of the triangle. As you slowly exhale, imagine the ball slowly moving down the other side of the triangle.”

Inhale … raise the ball to the top of the triangle … hold it for moment—exhale … lower the ball to the bottom of the triangle.” (Practice this five to ten times)

  1. Adding Relaxation Suggestions

“As you breath in and imagine the ball rolling to the top of the pyramid say to
yourself: ‘I am …’ as the ball rolls down the other side of the triangle say to yourself, ‘relaxing …’ ‘I am …’ Ball to the top. ‘Relaxing’ Ball to the bottom.” (Repeat five to ten times)

10. Waking Up From Relaxation

“Imagine that you are waking up in the morning from a deep and peaceful sleep. As you awaken you feel an urge to stretch and try to yawn. Take a deep, deep breath. Slowly come awake feeling the urge to stretch and yawn. Open your eyes, stretch your arms over your head. Come back fully awake feeling rested and alert.”

Macintosh HD:Users:tgorski:Documents:docs:0-Blogs:0-terrygorski_blog:TTG_Blog_Relaxation_Magic_Triangle_Method.doc


Treatment Manuals That Work

December 30, 2013
manuals

Well designed treatment manuals
make recovery easier for everyone.

By Terence T. Gorski, Author
December 30, 2013

Many clinicians feel frustrated when they are “mandated” to use TREATMENT MANUALS with patients. Here are some points to consider:

1. Treatment manuals are either well designed or poorly designed. WELL DESIGNED MANUALS are easy to use, present exercises in a logical series of progressive skill-building steps, and have exercises to practice the skills in real-life situations.

TREATMENT MANUALS THAT WORK

2. The language in well-designed manuals avoids both “PSYCHO-BABBLE”, highly technical psychological language, and RECOVERY TALK, the heavy use of 12-Step language, slogans, and platitudes.

Therapists require training in how to use a manual in individual and group therapy. They also need experience in treating the addiction or related problems that is the focus of each manual. Here are the basic steps that therapists need to take to become proficient in “manualized” treatment:

Step 1: Understand the therapeutic purpose of the workbook and the goal of each exercise. Review the way the sequence of information, questions, and suggested activities are used . Use each exercise to take the patient on a journey of new understanding.

STEP 2: Take ownership of the manual content by integrating it into your own personal style and be prepared to clarify or elaborate on the concepts in the manual in words, ideas, and examples that you are comfortable with.

STEP 3: Adapt the use of the manual to the structure and needs of the program you are working in.

STEP 4: Adapt the use of the manual to the needs of each individual patient. The key question is: Does the manual  meet the needs of the patients? If yes, the manual can be a valuable addition to traditional psychotherapy. If no, don’t use the manual.

Using a manual that does not address the important problems of a patient is the equivalent of giving patients the wrong medications. DON’T DO IT! Match specific manuals to the individual needs and treatment plans of patients.

It is important for therapist to work with management when adapting the use of manuals for use within a specific clinical program. How clinical staff negotiate with management for the appropriate use of treatment manuals is critical. Some negotiation styles cause head-to-head conflicts and power struggles. Others invite a collaborative process of evaluation that looks for the most effective way to use the manual with an individual patient.

Here are ways that the use of the manual can be adjusted to meet patient needs:

1. Sometimes the content of the manual needs to be delivered in smaller or bigger “chunks” of information that fit the patient’s cognitive ability and learning style.

2. Sometimes patients will respond better if the information is delivered in a different order. Feel free to adjust the sequence to match the patient’s interests and needs.

3. Skip sections of the manual that don’t fit the needs of the patient, or repeat knowledge and skills the patient already has.

4. The manual can be augmented with other handouts and exercises that can powerfully adjust the clinical approach guided by the manual.

5. Manuals are designed to have the exercises completed as homework assignments. These assignments help patients prepare for individual, group, and psycho-educational sessions.

6. When patients present workbook assignments in groups, it is usually not a good idea to have patients read their answers to each questions. This puts people to sleep. It is better to have a group reporting form that asks patients to answer these questions:

(1) What’s the most important thing that you learned from doing the exercise?

(2) What parts of the exercise were most difficult for you to complete?

(3) What parts do you want the group to help you understand and apply to your own situation?

(4) What can you do differently in your recovery as a result of what you learned by completing this exercise?

(5) How can what you learned help you to move forward in your recovery plan?

Treatment manuals provide guidelines and tools for patients to move forward in therapy. When used properly they can enhance the treatment process. Manuals ARE NOT straight jackets that restrict creativity and clinical reasoning.

Most importantly, treatment manuals don’t DO anything. The clinician who understands their value can use them to make their job easier and to improve the effectiveness of treatment. Well designed treatment manuals help therapists accomplish more while investing less time and energy.

Here are some well-designed and useful manuals to use in addiction treatment and relapse prevention:
TREATMENT MANUALS THAT WORK

GORSKI BOOKSGORSKI TRAINING/CONSULTATION


Recovery: SAMHSA’s Working Definition

October 15, 2013

SAMHSA’s Working Definition of Recovery  encompasses both mental disorders and/or substance use disorders. This will be a foundational definition for recovery as defined by the Affordable Health Care Act.

You can compare this with GORSKI’S WORKING DEFINITION OF RECOVERY

The Substance Abuse and Mental Health Services (SAMHSA)recognizes there are many different pathways to recovery and each individual determines his or her own way. SAMHSA engaged in a dialogue with consumers,persons in recovery, family members, advocates, policy-makers, administrators,providers, and others to develop the following definition and   for recovery.  The urgency of health reform compels SAMHSA to define recovery and to promote the availability, quality, and financing   services and supports that facilitate recovery for individuals.  In addition, the integration mandate in title II of the Americans with Disabilities Act and the Supreme Court’s decision in Olmstead v. L.C., 527 U.S.581 (1999) provide legal requirements that are consistent with SAMHSA’s mission to promote a high-quality and satisfying life in the community for  all Americans.

Recovery from Mental Disorders and/or Substance Use Disorders:  A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major dimensions that support a life in recovery:

•      Health:  overcoming or managing one’sdisease(s) or symptoms—for example, abstaining from use of alcohol,  , and non-prescribed medications if one has an addiction problem—and foreveryone in recovery, making informed, healthy choices that support physical and emotional wellbeing.

•      Home:  a stable and safe place to live;

•      Purpose: meaningful daily activities, such as a job, school, volunteerism,  family care taking, or creative endeavors, and the independence, income and resources to participate in society; and

•      Community: relationships and social networks that provide support, friendship, love,and hope.

 Guiding Principles of Recovery

Recovery emerges from hope:  The belief that recovery is real provides the essential and motivating message of a better future – that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them.  Hope is internalized and can be fostered by peers, families, providers, allies, and others.  Hope is the catalyst of the recovery process.

Recovery is person-driven:  Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s) towards those goals. Individuals optimize their autonomy and independence to the greatest extent possible by leading, controlling, and exercising choice over the services and supports that assist their recovery and resilience. In so doing, they are empowered and provided the resources to make informed decisions, initiate recovery, build on their strengths, and gain or regain control over their lives. 

Recovery occurs via many pathways:  Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds including trauma experiences that affect and determine their pathway(s) to recovery. Recovery is built on the multiple capacities,strengths, talents, coping abilities, resources, and inherent value of each individual.  Recovery pathways are highly personalized.  They may include professional clinical treatment; use of medications; support from families and in schools; faith-based approaches; peer support; and other approaches.  Recovery is non-linear, characterized by continual growth and improved functioning that may involve setbacks.  Because setbacks are a natural, though not inevitable, part of the recovery process, it is essential to foster resilience for all individuals and families. Abstinence from the use of alcohol, illicit drugs, and non-prescribed medications is the goal for those with addictions.  Use of tobacco and non-prescribed or illicit drugs is not safe for anyone. In some cases, recovery pathways can be enabled by creating a supportive environment. This is especially true for children, who may not have the legal or developmental capacity to set their own course.

 Recovery is holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit,and community.  This includes addressing: self-care practices, family, housing, employment, education, clinical treatment for mental disorders and substance use disorders, services and supports, primary healthcare, dental care,complementary and alternative services, faith, spirituality, creativity, social networks, transportation, and community participation.  The array of services and supports available should be integrated and coordinated.

Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Peers encourage and engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles, and community. Through helping others and giving back to the community, one helpsone’s self.  Peer-operated supports and services provide important resources to assist people along their journeys of recovery and wellness. Professionals can also play an important role in the recovery process by providing clinical treatment and other services that support individuals in their chosen recovery paths.  While peers and allies play an important role for many in recovery,their role for children and youth may be slightly different.  Peer supports for families are very important for children with behavioral health problems and can also play a supportive role for youth in recovery.

Recovery is supported through relationship and social networks: An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change.  Family members, peers, providers,faith groups, community members, and other allies form vital support networks.Through these relationships, people leave unhealthy and/or unfulfilling life roles behind and engage in new roles (e.g., partner, caregiver, friend,student, employee) that lead to a greater sense of belonging, personhood,empowerment, autonomy, social inclusion, and community participation. 

Recovery is culturally based and influenced: Culture and cultural background in all of its diverse representations including values,traditions, and beliefs are keys in determining a person’s journey and unique pathway to recovery. Services should be culturally grounded, attuned,sensitive, congruent, and competent, as well as personalized to meet each individual’sunique needs.

Recovery is supported by addressing trauma:  The experience of trauma (such as physical or sexual abuse, domestic violence, war,disaster, and others) is often a precursor to or associated with alcohol and drug use, mental health problems, and related issues.  Services and supports should be trauma-informed to foster safety (physical and emotional)and trust, as well as promote choice, empowerment, and collaboration.

Recovery involves individual, family, and community strengths and responsibility:  Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery. Individuals should be supported in speaking for themselves. Families and significant others have responsibilities to support their loved ones, especially for children and youth in recovery. Communities have responsibilities to provide opportunities and resources to address discrimination and to foster social inclusion and recovery.  Individuals in recovery also have a social responsibility and should have the ability to join with peers to speak collectively about their strengths, needs, wants, desires, and aspirations.

Recovery is based on respect: Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems – including protecting their rights and eliminating discrimination – are crucial in achieving recovery.  There is a need to acknowledge that taking steps towards recovery may require great courage. Self-acceptance, developing a positive and meaningful sense of identity, and regaining belief in one’s self are particularly important.

SAMHSA has developed this working definition of recovery to help policy makers, providers, funders, peers/consumers, and others design,measure, and reimburse for integrated and holistic services and supports to more effectively meet the individualized needs of those served.

Many advances have been made to promote recovery concepts and practices.  There are a variety of effective models and practices that States, communities, providers, and others can use to promote recovery. However, much work remains to ensure that recovery-oriented behavioral health services and systems are adopted and implemented in every state and community.  Drawing on research, practice, and personal experience of recovering individuals, within the context of health reform, SAMHSA will lead efforts to advance the understanding of recovery and ensure that vital recovery supports and services are available and accessible to all who need and want them.

A CRITICAL REVIEW OF THE SAMHSA DEFINITION OF RECOVERY

The big problem with the SAMHSA definition of recovery is that it does not specifically answer the question “recovery from what?” By including chemical and behavioral addictions and then expanding the universe to all mental disorders, it misses the mark.

I believe the research clearly shows that there are non-addictied substance abusers who have episodes of abuse related to stage of life and life circumstances. A key defining idea of the DSM-III and IV criteria is that there are substance dependence disorders, generally called addiction, that are marked by a pattern of compulsive use, the description of matches the idea of progressive loss of control discussed, is consistent with early research which has be reexamined over more the forty years and found to be powerful descriptions.

The treatment of recovery from non-addictive substance abuse is different, in many ways from the treatment o substance dependence (addiction). Substance dependence (addiction) with carries with it an underlying impairment of the reward centers of the brain that do not rapidly return to normal and produce long-term cognitive impairment often described as Post Acute Withdrawal (PAW) or Protracted Withdrawal. PAW is stress sensitive (i.e. stress increases the degree of impairment in cognitive functioning) and as a result is highly correlated with stress-induced relapse models.

We must deal with this critical question: What exactly is the disease or disorder we are dealing with? How severe? What stage of severity? What past treatment? What coexisting mental or physical disorders?
The over-generalization of a recovery process from everything, implies that addiction, abuse, and mental disorders are essentially the same thing. There is compelling evidence that this is not the case. There are critical differences between disorders which dictate disorder specific treatment and differences in the recovery process.

I had hoped we gotten past the “addiction is anything you want it to be phase” in the development of the addiction treatment profession. Apparently I was wrong.

In my opinion the SAMHSA operational definition of recovery and the DSM 5 reformulation of criteria for addictive disorders is a step back into vague generalities that maintain tired old disagreements that have been settled in the literature.

A precise definition of the disorder being treated and specific principles and practices that professionals and recovering people can use as they progress in recovery are extremely important steps forward. This is a controversial position that has been systematically avoided in the profession for forty years. This is a controversial position that has been systematically avoided in the profession for forty years.

LANGUAGE PROGRAMS THE BRAIN! SLOPPY THINKING LEADS TO DISORGANIZED NEUROCOGNITVE FUNCTIONING.
Unfortunately, I don’t see it changing soon.

ON THE INTERNET:

1.  GORSKI’S WORKING DEFINITION OF RECOVERY
2. SAMHSA’s WORKING DEFINITION OF RECOVERY 


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