Treating Methamphetamine Addiction Utilizing the Developmental Model of Recovery Presented by Chip Abernathy, LPC, CAC www.ridgeviewinstitute.com Addiction Substance dependence – addiction – is a brain disease characterized by loss of control over psychoactive substances. This loss of control causes problems in all areas of the addict’s life: physically, psychologically, socially, and spiritually. Addiction causes harm to the person’s family and to society as well. Substance dependence (addiction) is a chronic, progressive, relapsing, incurable and potentially fatal disease if left untreated. Methamphetamine Methamphetamine is a stimulant drug with a very high potential for misuse and addiction. Treatment-seeking stimulant users often have some common behaviors that include, but are not limited to… Extreme financial irresponsibility Lack of routine self-care behaviors (e.g. eating, sleeping, dental hygiene, bathing) Excessive sexual behavior Severely deteriorated employment/educational performance Escalating irresponsible behavior to family and spouse (excessive spending for drugs, failure to care for children) Methamphetamine Some common mental and emotional states that are often present with methamphetamine users during treatment include, but are not limited to… Dissatisfaction with life Intense anxiety, fear, guilt, and shame over medical, fiscal, legal, and personal relationships Anergia (lack of energy) and anhedonia (inability to feel pleasure) during periods of abstinence Anger, paranoia, and irritability Low frustration tolerance Meth users seeking treatment services are often skeptical and ambivalent about treatment, and come across as resistant. Special Considerations in Treating Methamphetamine Addicts It is important to stay aware of special considerations in the treatment of whatever type of substance dependence that is presented. Assessment for co-occurring mental disorders should always be a part of the assessment process. After stopping using, meth addicts commonly experience… Cognitive impairment Anxiety Depression Treatment outcomes improve if the client’s mental health problems are addressed during treatment. Treatment of meth addiction can be just as successful as treatment for any other substance. Assessment Considerations People with substance dependence enter treatment with various problems, including co-occurring disorders, and widely different levels of… Insight Motivation Resources All of these factors need to be considered and addressed on an individual basis with each person. Treatment Planning: General Treatment planning needs to include consideration of the addicted person’s Presenting problems Possible detoxification needs; look into concurrent use of other drugs including alcohol Level of functioning/stability Motivation for change Risk of relapse Mental status Psychosocial stressors including living environment Treatment Planning Assessment Considering Stage of Recovery As part of the ongoing assessment process that occurs during treatment, providers need to determine as accurately as possible (which includes exploration of past recovery attempts) the person’s Current stage of recovery Tasks within that stage of recovery that have been accomplished Tasks that still need to be accomplished Past difficulties accomplishing identified recovery tasks Potential problems regarding accomplishing those tasks now Treatment Planning: Goals, Objectives and Interventions Once the stage of recovery assessment process is complete, treatment providers need to have treatment plans that specify Treatment goals Treatment objectives for the addicted person Interventions that the providers will perform to help the person achieve their treatment objectives Treatment plans should be modified as needed during treatment, and should be presented in behavioral terms that are easy for the addicted person to comprehend. Recovery Recovery means living a meaningful and comfortable life without the need for alcohol or other drugs. In recovery we Move from dependence on substances to… full physical, psychological, social and spiritual health Stop using and begin to heal the damage done to our bodies, minds, relationships and spirit Recovery is more than just healing the damage. It is living a lifestyle that promotes continued physical, psychological, social and spiritual health. Recovery Skills The skills necessary for long-term recovery are all directed at finding meaning and purpose in life. Recovery is… A way of thinking, a way of acting, and a way of relating to others. It is a philosophy of living. It requires the daily effort of working a recovery program. Gorski’s Developmental Model of Recovery Recovery is a developmental process during which we go through a series of stages. It is a gradual effort to learn new and more complex skills. We do not use, no matter what, and we do our best to solve problems that we encounter. Sometimes we succeed, sometimes we fail. Whatever the outcome, we learn from the experience and try again. Beliefs Upon Which Gorski’s Developmental Model of Recovery (DMR) are Based 1. 2. 3. 4. Recovery is a long-term process that is not easy. Recovery requires total abstinence from alcohol and other drugs, plus active efforts towards personal growth. There are underlying principles that govern the recovery process. The better we understand these principles, the easier it will be for us to recover. (Continued) Beliefs on which Gorski’s DMR are Based (Continued) 5. 6. 7. Understanding alone will not promote recovery; the understanding must be put into action. The actions that are necessary to produce full recovery can be clearly and accurately described as recovery tasks. It is normal and natural to periodically get stuck on the road to recovery. It is not whether you get stuck that determines success or failure, but it is how you cope with the stuck point that counts. The Stages of the Developmental Model of Recovery To understand recovery, it is helpful to divide the process into stages. These six stages are (1) Transition, (2) Stabilization (3) Early recovery (4) Middle recovery (5) Late recovery (6) Maintenance Transition Stage The Beginning of Recovery The major theme of the transition stage is giving up the need to control alcohol or other drug use. During the transition stage we Recognize we have problems with alcohol or other drugs, but we think we can solve them by learning how to control our use. This stage ends when we Recognize we are not capable of control – that we are “powerless” over our addiction – and that we need to stop using in order to regain control of our lives. Transition Stage Goals Three major goals need to be accomplished during the transition stage: Recognize that we have lost control over our use of alcohol and/or other drugs Recognize that we can’t control our use because we are addicted Make a commitment to a program of recovery that includes the help of others Transition Stage Tasks The transition stage of recovery starts while the addicted person is still using. The tasks that need to be accomplished in order to consider the transition stage complete are: 1. Development of motivating problems 2. Failure of normal problem solving 3. Failure of controlled use strategies 4. Acceptance of the need for abstinence and the need for help 12 Step Programs Although the 12 Step Program is not the only way to recover from addiction, it is the most effective way, and the most way often recommended by treatment centers . Programs that are geared towards having the 12 Step Program be the primary agent of change in treating addiction, and work in combining that with professional addiction counseling, psychiatric care when needed, and medical care when needed, are going to be effective and successful programs. Alcoholics Anonymous (AA) has been in existence since 1935. Narcotics Anonymous (NA) has been in existence since 1953. Crystal Meth Anonymous (CMA) is relatively new, but is helpful for many meth addicts. The 12 Steps of Narcotics Anonymous 1. 2. 3. 4. 5. 6. We admitted that we were powerless over our addiction, that our lives had become unmanageable. We came to believe that a Power greater than ourselves could restore us to sanity. We made a decision to turn our will and our lives over to the care of God as we understood Him. We made a searching and fearless moral inventory of ourselves. We admitted to God, to ourselves and to another human being the exact nature of our wrongs. We were entirely ready to have God remove all these defects of character. 7. 8. 9. 10. 11. 12. We humbly asked Him to remove our shortcomings. We made a list of all persons we had harmed, and became willing to make amends to them all. We made direct amends to such people wherever possible, except when to do so would injure them or others. We continued to take personal inventory and when we were wrong promptly admitted it. We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs. Transition Stage and 12 Step Recovery From a 12 Step recovery prospective, we gear treatment towards helping those with addictive disease work the first three steps during the transition stage. Step One: Step Two: Step Three: I can’t handle my drug using anymore Help is available from other people and a Higher Power It is wiser to turn my life and will over to a loving power greater than myself, than to a destructive power greater than myself Stabilization Stage The major theme of the stabilization stage is recuperating from damage caused by addictive use. We physically recover from acute withdrawal and post acute withdrawal. We learn to manage addictive preoccupation. We learn to manage stress, emotions, and problems. We develop hope and motivation. With methamphetamine addiction, the stabilization stage of recovery can be particularly challenging due to the severity of cognitive impairment caused by methamphetamine usage. Post Acute Withdrawal and Addictive Preoccupation Post Acute Withdrawal Syndrome starts after acute withdrawal ends. This syndrome often lasts for several months. Symptoms include difficulty with… Thinking clearly Remembering Stress management Emotion management Sleeping restfully Physical coordination Addictive Preoccupation is a type of delusional thinking associated with being a sober addict/alcoholic and includes… Euphoric recall (recalling only the positives about using) “Awfulizing” sobriety (focusing on only the negatives about sobriety) Magical thinking about future use (thinking using will somehow make things better) Left unattended, this becomes obsession, compulsion and craving. Management of Post Acute Withdrawal and Addictive Preoccupation Some things that are helpful for management of Post Acute Withdrawal include, but are not limited to, … Having a structured lifestyle Getting enough rest Healthy diet and eating habits Regular exercise Social support, esp. AA/NA Deep-breathing relaxation skills Emotion management skills Conflict management skills H.A.L.T. – Don’t get too Hungry, Angry, Lonely or Tired. In addition to 12 step program coping skills, such as calling on others and a Higher Power, some things that are helpful for managing Addictive Preoccupation include, but are not limited to, … Euphoric recall – Force yourself to remember specific negative experiences involving using. “Awfulizing” sobriety – Force yourself to consider positive things about recovery. Magical thinking about future use – Force yourself to consider what would actually happen if you used. Cognitive Impairment and Uncomfortable Emotional States Methamphetamine use causes cognitive impairment and very uncomfortable emotional states that can last for several months after stopping use of the drug. After stopping using, stimulant dependent individuals are often… Frightened Disoriented Anxious Ashamed Treatment Considerations Considering Stabilization Needs Treatment providers need to provide Thorough but brief assessments Clear orientation to treatment Clear expectations Involving supportive significant others whenever possible helps with problems that can occur due to cognitive impairment and emotional damage caused by meth addiction. Matrix Model and First Months of Recovery The Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders is particularly well-suited for people in the first few months of recovery from methamphetamine dependence. It is presented in such a way that addicts and their families can more easily grasp key recovery concepts by Helping to simplify some of these rather complicated concepts, and Helping to show how they all fit together They will use these tools throughout their lives in recovery. Attitude and Behaviors of Treatment Providers Treatment providers should strive to be Warm Friendly Calm Empathic Engaging Not harshly confrontational Straightforward Nonjudgmental. An Important Area of Focus During Stabilization Stage Providers need to help addicts… To begin regaining control of their thinking, emotions, and actions through teaching sober coping skills To connect with others in recovery, and To find hope. Early Recovery The major theme of the early recovery stage is internal change related to addiction and recovery. In early recovery we… Demystify the miracle that has started to occur through working the first three steps by continuing with further step work Begin to consciously understand our addiction, and what is required of us if we are to stay in recovery (Continued) …. Early Recovery (Continued) In early recovery we… Learn the words and concepts necessary to understand what has happened to us and what we need to do to maintain the positive change Are able to explain the recovery process to others by the end of the early recovery stage Early Recovery Recovery requires two kinds of change: 1. Unconscious – a subtle change in feeling and belief that motivates us to change what we do. 2. Conscious – an understanding of the laws and principles that create and maintain the change. Working Steps 4 – 7 of AA/NA with the help of a sponsor (an experienced member who serves as a personal mentor in recovery) during early recovery provides an excellent way for this process to occur. Early Recovery Tasks The tasks that need to be accomplished in early recovery are… Full conscious recognition of addictive disease Full acceptance and integration of the addiction Learning non-chemical coping skills Short-term social stabilization Developing a sobriety-based value system Early Recovery Goals During the early recovery stage, we work to… Understand the role our addiction played in our lives and to accept that. Resolve the pain it caused. Develop a value system that is part of our new life in recovery. With diligent effort, early recovery tasks usually take about 6 to 18 months to complete. Middle Recovery The major theme of middle recovery is external change (repairing the lifestyle damage caused by addictive use and developing a balance lifestyle). The goal of middle recovery is to learn to function well in the family, in intimate relationships at work and with friends, and to learn to handle the ordinary ups and downs of life. We strive for balance. Successfully completing all the tasks of the early recovery stage provides the foundation needed to move successfully into and through middle recovery. Middle Recovery Achieving Lifestyle Balance By the end of early recovery, most of us… Are regularly involved in 12 step recovery (beyond simply attending meetings) Are possibly in therapy Have developed adequate coping skills to stay employed, manage being in a relationship with someone, manage our finances reasonably well, and not break laws In early recovery, our attention has been on our number one priority – not drinking or using other drugs and learning the skills necessary to stay sober. We are now coping on a day-to-day basis, but we do not have a well-balanced or satisfying lifestyle. Middle Recovery Making a Choice During middle recovery, our lives are much better than they were during active addiction, but we still have a great deal of work to do. Middle recovery confronts us with a major choice: Do we begin to rebuild our lifestyle, using recovery principles, or do we try to avoid making any real changes? At this point, some people get stuck, while others move ahead. Those who get stuck stop the recovery process. The thinking is: “I’m not using and I’m going to meetings! That’s all I need to do!” Middle Recovery Resolving the Demoralization Crisis Those who have the courage to move ahead are willing to confront reality. They are willing to pay the price to develop a balanced lifestyle and find meaning and purpose in sobriety. This period can be a big letdown. We begin to ask the question, “Why did I stay clean all this time, and do all this work, if I still have all these problems?” Resolving that letdown is one of the tasks of middle recovery. It is a period of high risk for relapse. To resolve this demoralization crisis, we need a strong belief that it is possible to repair past damage and create a better life. Middle Recovery Repairing the Damage The next task of middle recovery is repairing the damage caused by our addiction. We make amends for harm we have caused. We do it because of a universal principle of recovery that has guided us thus far and continues to guide us throughout our lives in recovery: We are not responsible for our disease but we are responsible for our recovery. Steps 8 and 9 of AA/NA address making amends. To amend something is to change it. We do not simply apologize for harm done; we also do what we can to make things right. Middle Recovery Keep Doing the ‘Next Right Thing’ In middle recovery we build on the recovery skills, recovery principles, and sobriety-centered value system that we have worked hard to establish up to this point. We work towards always trying to do the ‘next right thing.’ Some of the things that help us do this include, but are not limited to, … Actively and deliberately taking care of our health physically, psychologically, and spiritually Taking responsibility for our actions Asking for help when needed and being helpful to others Using good judgment in all major life areas Dealing with life’s ups and downs without using Middle Recovery Establishing Lifestyle Balance Establishing lifestyle balance is an overall goal of middle recovery. Relapse occurs during this stage when recovering people are unwilling or unable to step out of the comfort zone of early recovery and to take on and accomplish the increasingly difficult tasks of middle recovery described thus far. Another part of establishing this lifestyle balance is stepping out beyond the 12 step fellowship and having relationships with people outside the program who help to continue to bring meaning and purpose to our lives. Completing Middle Recovery We are prepared to move forward into late recovery when we… Have completed the tasks of middle recovery Continue to take personal inventory and promptly admit it when we are wrong (Step 10 of AA/NA) Are using recovery principles and skills to manage our thinking, feeling, actions and relationships Are active participants in meaningful relationships both inside and outside the 12 step fellowship Continue to live our lives in a way that demonstrates that we keep our recovery our top priority, even when it is difficult Late Recovery The major theme of the late recovery stage is growing beyond childhood limitations. We enter what Gorski describes as late recovery when we, in spite of all the progress we’ve made, we really don’t feel happy. We might be wondering, “Is this all there is to sobriety?” Late Recovery Dealing with Family of Origin Issues The cause of unhappiness and dissatisfaction with our lives after middle recovery is often caused by growing up in a dysfunctional family. In dysfunctional families we learn self-defeating ways of coping with life that can lower the quality of our recovery and increase the risk of relapse. Late recovery is a time to free ourselves from the beliefs, uncomfortable feelings and patterns of behavior that we learned as children. Late Recovery Recognizing Childhood Problems Those of us who came from healthy families move through late recovery quickly and without a great deal of pain. If we were raised in a dysfunctional family, however, the process is more difficult. Leaning some of the differences between how healthy families and dysfunctional operate can be helpful when examining our own experience during childhood. Healthy vs. Dysfunctional Families A Few Differences Healthy, functional families teach by example that we … Can look honestly at ourselves and the world around us Don’t have to be perfect; we can be ourselves, even with flaws Can express our thoughts and feelings, whether pleasant or unpleasant to express Can value our ability to assess and solve problems Can rely on others to treat us with respect and dignity Unhealthy, dysfunctional families teach by example that we … Cannot trust our perceptions or feelings Should never express honest thoughts and feelings about what is wrong in the family Can usually expect to be disappointed Should perceive the world as threatening, unsafe, and contradictory Need to be rigid and inflexible in order to survive Common Problems in Late Recovery 10 common problems that often need attention in late recovery are: 1. Personal problem solving: We have difficulty solving important personal problems but are able to solve similar problems for other people. 2. Inability to manage feelings: We have difficulty managing our feelings and emotions. 3. Rigid behavior: We have rigid habits that make it difficult to change our behavior when we need to. 4. Rescuing: We rescue or save others to the extent that it causes us problems. Common Problems in Late Recovery (Continued) 5. 6. 7. 8. 9. 10. Complying: We quietly fit in by doing what other people expect. Entertaining: We entertain others in order to divert attention from problems. Peacemaking: We must assure that there is peace at any cost. Self-sacrificing: We tend to accept the blame for the problems of others Troublemaking: We make trouble by acting out and tend to disrespect or break rules. Blaming: We tend to blame others for our problems. Approaching Common Problems in Late Recovery The 10 common problems just noted have two things in common: They are all related to what we learned in our family of origin. We feel compelled to continue to act out these problems even though we know better. We need to ask ourselves some questions about each of these common problems: 1. How often we experienced each behavior as a child 2. How often we currently experience it at home or at work 3. If this is a problem we feel we need to work on in recovery Working on Problems in Late Recovery In the earlier stages of recovery, we have worked on family of origin issues through working the 12 steps and managing the related problems the best we could. When self-defeating thinking, attitudes, and patterns of behavior persist, and life is not satisfying even though we are working a good program of recovery, we should seriously consider… Continuing to work a 12 step recovery program – and… Getting involved in professional counseling or therapy Finishing Late Recovery and Moving On to the Maintenance Stage Remember that family of origin issues do not cause addiction. Addiction is caused by a combination genetic susceptibility and the use of alcohol or other drugs. People from both functional and dysfunctional families become addicted. In late recovery we need to remember that recovery is possible but it requires work. We must… Be willing to examine the effects of our childhood on our lives, Be willing to change, and then Do the work necessary to change. Maintenance Stage The final period of recovery is maintenance. It lasts a lifetime. The major theme of the maintenance stage of recovery is balanced living and continued growth and development. We will need to… Continue keeping recovery our top priority, which includes not using, attending AA/NA regularly, working the 12 steps, calling our sponsor, and helping others Do a daily inventory and correct problems as needed Have a strong commitment to grow in our recovery Continuing Step Work Steps 10, 11 and 12 of AA/NA become a priority in the maintenance stage. In step 10, we continue to take personal inventory, examining our attitude, our motives, and our behavior. We promptly take corrective actions as needed. In step 11, we continue to develop an ever-increasing awareness of spirituality; we search out our unique meaning and purpose in recovery. In step 12, we practice the principles of recovery in our daily lives, always remembering “We keep it by giving it away.” Maintaining a Recovery Program Even after many years of good recovery, we need to never forget that addiction is a disease that is… incurable, chronic, progressive, relapsing and potentially fatal if not attended to on an ongoing basis. We don’t have to do anything to relapse; we simply must not do what we need to do to recover, and the disease does the rest. Fortunately, what we need to do to recover in the maintenance stage is basically the same things we learn to do as newcomers. We “keep it simple” in our recovery program. Effective Day to Day Coping In maintenance, we are not problem-free, but we are… Learning to manage the problems of ordinary living efficiently. We don’t stop having problems, but we… Upgrade to better problems, and we Become better at solving problems. When we are working a good program, we can respond from a position of self-confidence and self-worth, rather than from a position of insecurity and fear. Continued Growth and Development Human beings are designed to seek truth, meaning and purpose in life. We constantly strive for… More understanding New challenges Forward movement in our lives We are not free to choose whether or not we grow and change. But we are free to choose the direction of that growth and change. Dry Drunk When we stop growing, a dry drunk is just around the corner. A dry drunk means that we are not using, but we are miserable from not working our program. Stress builds up Eventually Post Acute Withdrawal symptoms emerge The relapse process begins, with relapse warning signs getting progressively more severe if not managed with good recovery principles and skills A chemical relapse can occur if warning signs are continually ignored or not managed When Continued Growth is Difficult Even for those of us with long-term, good recovery, we can return to dealing with stuck points in recovery with denial and evasion. Old, self-defeating ways of coping can reappear. During difficult times such as these during the maintenance stage, we know how to take responsibility for our recovery by… Not using no matter what, and paying attention to our thinking, feelings, actions, and relationships (personal inventory) Being open to growth and accepting that we are fallible human beings Doing the best we can with what we have Coping with Changes and Complications As we get older in recovery, we must learn to cope with the normal changes that occur as part of the aging process. We need to do that simultaneously with keeping our recovery as our top priority. So… How do we do that? One day at a time, we… Remember who we are, what we are, and where we came from by having relationships with others in recovery and by sticking with the “basics” – not using, going to AA/NA, working the steps, calling our sponsors, and having conscious contact with our Higher Power Learn from our own experience and the experience of those who came before us Stay teachable Relapse: A Process, Not an Event Relapse is the process of becoming so dysfunctional in recovery that we eventually see our only options as Suicide, Emotional collapse, Or return to alcohol or other drug use. One way to distinguish a chemical relapse, versus simply returning to using again, is that the following elements are present: We see our substance use as being a serious problem We make a commitment to ourselves or others that we will stop using We stop using and attempt to stay stopped High Risk Factors and Trigger Events for Relapse 1. 2. 3. 4. 5. 6. High Risk Factors High-stress personality High-risk lifestyle Social conflict or change Poor health maintenance Other illness Inadequate recovery program 1. 2. 3. 4. 5. Trigger Events High-stress thoughts Painful emotions Painful memories Stressful situations Stressful interactions with other people A Few Common Relapse Warning Signs Early and Middle Stage Internal Dysfunction Early Warning Signs 1. Difficulty with… 2. Thinking clearly 3. Managing feelings 4. Remembering 5. Managing stress 6. Sleeping restfully 7. Physical coordination 8. Shame, guilt, hopelessness External Dysfunction Later Warning Signs 1. Avoidance and defensive behavior 2. Crisis building 3. Immobilization 4. Confusion and overreaction 5. Depression Relapse Warning Signs Late Stage Warning Signs/ Lapse, Relapse Loss of Control Still Later Warning Signs 1. Poor judgment 2. Inability to take action 3. Inability to resist destructive impulses 4. Conscious recognition of loss of control 5. Option reduction 6. Emotional or physical collapse Chemical Lapse/Relapse Return to Using 1. Initial use of alcohol or other drugs 2. Severe shame, guilt and remorse 3. Loss of control over use 4. Development of health and life problems Coping with Stuck Points in Recovery Each of us will get stuck in our recovery from time to time. Getting stuck in recovery is neither good nor bad; it simply is. Those of us who are successful in recovery cope with our stuck points through a process of recognition and problem solving. Coping With Stuck Points in Recovery We learn how to recognize we are having a problem and that we are stuck in our recovery. We … Accept that this is OK, knowing that as fallible human beings, we reserve the right to not have all the answers. Detach from the problem while we seek help from others. Finally, when we are prepared, we take responsible action. The Relapse-Prone Style of Coping with Stuck Points Denial and Evasion (The relapse-prone style) Evade/deny the stuck point Stress Compulsive behavior Avoid others Problems escalate Evade/deny new problems The Recovery-Prone Style of Coping with Stuck Points Recognition and Problem Solving (The recovery-prone style) Recognize a problem exists Accept that it is OK to have problems Detach to gain perspective Ask for help Respond with action when prepared References Alcoholics Anonymous. Alcoholics Anonymous (The Big Book, third edition). New York: Alcoholics Anonymous World Services Office, 1976. Center for Substance Abuse Treatment (CSAT). Treatment for Stimulant Use Disorders. Treatment Improvement Protocol (TIP) Series, Number 33. DHHS Pub. No. (SMA) 99-3296. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999. Center for Substance Abuse Treatment (CSAT). Client’s Handbook: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders. 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