Facilitator s Manual. Living Clean & Sober

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Facilitator s Manual Living Clean & Sober Ottawa Drug Treatment Court Program Rideauwood Addiction and Family Services Table of Contents Introduction 4 Clinical Model 4 Living Clean & Sober Group
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Facilitator s Manual Living Clean & Sober Ottawa Drug Treatment Court Program Rideauwood Addiction and Family Services 2007 2 Table of Contents Introduction 4 Clinical Model 4 Living Clean & Sober Group 4 Critical Tasks 4-5 Participants 5 Compatibility within the DTCO Continuum 5 Prerequisite 5 Clinical Approach 6 Structure and Content 7 Didactic session 7 Social recreational activity 7 Living Clean & Sober Group Presentation Guide 8 Session 1 High Risk Situations Session 2 Relapse Traps Session 3 Refusal Skills Session 4 Support Systems Session 5 Family Relationships Session 6 Pro-Social Activities 21 Appendix A Session Reviews INTRODUCTION Clinical Model The primary therapeutic approach utilized in this group is Cognitive Behavioural Therapy (CBT). CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support as treatment for substance dependence and is consistent with effective correctional treatment approaches. In particular, evidence points to the durability of CBT's effects as well as its effectiveness with subgroups of more severely dependent substance abusers and high risk offenders. No significant differences have been found in outcome or retention for participants who seek treatment because of court or probation pressure and those who have DSM-IV diagnoses of antisocial personality disorder or other Axis II disorders, nor has outcome varied by participant race/ethnicity or gender. This group also employs elements of the Community Reinforcement Approach (CRA), which is compatible with CBT as it understands substance abuse in terms of its antecedents and consequences. Specifically, the group borrows from CRA in its approach towards addressing social and recreational counselling, drug/crime refusal training, as well as utilizing contingency management strategies. While attending 12-step meetings is not required or strongly encouraged in CBT, participants may find attending meetings very helpful in their efforts to become or remain abstinent. CBT therapists encourage participants to view going to meetings as a coping strategy when faced with urges to use and as a very useful and important strategy to cope with craving; however, therapists will also encourage participants to think about and have ready a range of other strategies as well. Living Clean and Sober Group This group is designed to help participants recognize, avoid, and cope. That is, recognize the situations in which they are most likely to use drugs/alcohol, avoid these situations when appropriate, and cope more effectively with a range of problems and problematic behaviours associated with substance abuse. The group is structured, goal-oriented, and focused on the immediate problems faced by drug/alcohol abusers entering treatment and struggling to control their substance use. This group helps participants unlearn old habits associated with substance use and learn or relearn healthier skills and habits. Critical Tasks The group addresses several critical tasks that are consistent with CBT and CRA and essential to successful substance abuse treatment. Teach coping skills: This group will help participants recognize the high-risk situations in which they are most likely to use substances and to develop other, more effective means of coping with them. 4 Change reinforcement contingencies: By the time treatment is sought, many participants spend most of their time acquiring, using, and recovering from substance use to the exclusion of other experiences and rewards. This group focuses on identifying and reducing habits associated with a drug-using lifestyle by substituting more enduring, positive activities and rewards. Improve interpersonal functioning and enhance social supports: This group includes training in a number of important interpersonal skills and strategies to help participants expand their social support networks and build enduring, drug-free relationships. Lifestyle changes: High levels of satisfaction in a drug free lifestyle are needed to compete with the reinforcement derived from drug use and the drug using lifestyle. Therefore, increasing satisfaction in these areas is a major goal for reducing the probability of continuing or resuming drug use. This group focuses on enhancing recreational activities, social networks, and family relationships. Contingency management: Abstinence is difficult to achieve and may not result in sufficient immediate natural rewards, particularly in its early stages. The group provides prompt and frequent reinforcement, as well as additional motivation by providing vouchers that can be redeemed for items that contribute to the participant s treatment goals. Participants The following participants are generally not appropriate for this group: Those who have psychotic or bipolar disorders and are not stabilized on medication. Those who have no stable living arrangements Those who are not medically stable Compatibility within the DTCO Continuum of Care This group fits within the larger context of the DTCO Treatment Program. It builds on, and is supported by, material covered in other parts of the treatment regime. A major task of the therapist is to achieve an appropriate balance between attending to the relationship and delivering skills training. Empathic delivery of skills training to help participants manage their lives more effectively forms the basis of a strong working alliance. Prerequisite Participants will have completed the DTCO Basics program and/or be familiar with its contents. 5 Clinical Approach A major issue for DTCO participants is reducing availability to drugs and alcohol. Most participants entire social network has been based on committing crimes and obtaining and using substances. Significant social changes are required to maintain abstinence and participants need to learn to take independent steps toward limiting availability. The facilitator should carefully direct questions to identify covert indicators of ambivalence and resistance to change. Failure of participants to take initial steps toward removing triggers and avoiding drugs/alcohol may reveal a number of clinically significant issues. If they are unwilling to take independent steps toward limiting availability, they may be expecting that mere exposure to treatment will produce abstinence with little or no effort on their part. Conversely, determining the steps participants have already taken toward reducing substance availability and criminal involvement may be an invaluable index of their internal and external resources. Therapists must exhibit empathy and good listening skills. They should convey an understanding of the participant s situation and its inherent difficulties. As a general rule, confrontation is strongly discouraged as a means of gaining compliance with therapeutic activities. Rather, therapists should use their professional counselling skills and appropriate behavioral procedures (e.g., prompts, shaping successive approximations, social reinforcement) to gain treatment compliance. For example, if participants are constantly late for appointments, therapists should not lecture them on promptness or lack of motivation but, instead, facilitate a discussion about the time demands of treatment. Throughout treatment, empathy should be shown whenever participants are ambivalent about or are having difficulty making changes in any problem area. Non-judgmental feedback is used to help participants make decisions about specific goals or lifestyle changes. Therapists avoid making moral or value judgments and, instead, exhibit genuine empathy and consideration for the difficult decisions and behaviour changes participants must contemplate. Therapists should provide frequent social reinforcement for all appropriate efforts and changes exhibited by participants. They should take advantage of all opportunities to help participants feel that they are making progress. This is important since, for many participants, change will be slow and difficult. 6 Structure and Content This weekly group has an open intake and each session is divided into two parts. The first part consists of a didactic CBT based session and the second part consists of a CRA based social recreational activity. Didactic session: This section comprises 6 sessions, each approximately 1 hour long. Each session begins with a brief review of all material covered in previous sessions followed by the presentation of new material. Attendance at all 6 sessions is mandatory for all Phase I DTCO participants (unless exempted by their case manager). Material coved in this session includes: High Risk Situations Relapse Traps Refusal Skills Support Systems Family Relationships Pro-Social Activities Viewing and discussion of selected videos from the Beat the Street series Social recreational activity: The second part of the group is approximately 2-3 hours long and consists of a social recreational activity in the community. Attendance is mandatory for all Phase I participants and all post-phase I participants not actively involved in employment or educational pursuits. Activities include: Recreational sports softball, volleyball, bowling, golf, tennis, etc. Cultural activities visiting museums, art galleries, concerts, festivals, etc. Leisure activities walking, hiking, bicycling, swimming, canoeing, etc. Local attractions experimental farm, sugar bush, bird sanctuary, etc. Volunteering leaf raking and snow shoveling for seniors in the community, etc. Risk All participants will be assessed by the DTCO Nurse Practitioner and cleared to engage in recreational activities such as; walking, softball, volleyball, swimming, bicycling, etc. A Rideauwood staff member certified in First Aid and CPR will attend all activities. A first aid kit and defibrillator will be available at all activities requiring physical exertion. 7 8 Living Clean & Sober Group Presentation Guide Session 1 High Risk Situations Session 2 Relapse Traps Session 3 Refusal Skills Session 4 Support Systems Session 5 Family Relationships Session 6 Pro-Social Activities 9 SESSION 1 HIGH RISK SITUATIONS Purpose To assist participants in recognizing that exposure to High Risk Situations increases the potential for relapse and to provide cognitive behavioural tools for avoiding them. Session Objectives 1. Participants will be able to recall the five characteristics of People, Places and Things. 2. Participants will be able to recall the five components of Zero Access. 3. Participants will be able to self-identify with at least 3 Big Lies and provide Counters for each. 4. Participants will be able to describe what a Big Lie is and recall at least 3 of them. Introduction In order to achieve abstinence, it is critical to reduce availability to drugs and alcohol. Most participants entire social network and lifestyle has been based on committing crimes and obtaining and using substances. 1. Review Outside Me Cues from Basics. List them on the board. I don t control them They don t control me They will always be there I can learn to deal with them differently, but I can t change them I am not responsible for them 2. Connect High Risk Situations to Outside Me Cues by discussing how People, Places and Things can act as relapse triggers. Ask for examples and write them on the board. 3. Introduce Zero Access by explaining that abstinence is not achieved by simple exposure to treatment, but by taking active deliberate steps to make changes. List the 5 components of Zero Access on the board (explain the ø symbol). Ø People who are high or supplying drugs or alcohol Ø People who use drugs/alcohol or commit crime 10 Ø Places where people sell or use drugs including alcohol Ø Places you have committed crimes Ø Extra $$$ 4. Explain that it is impossible to be 100% in Zero Access all the time, but that Zero Access is an intention. 5. Illicit examples of how being in access has led to relapse in the past. 6. Introduce and discuss The Big Lies (listed in the participant s workbooks) as rationalizations that are often used to justify being in high risk situations. Have them select any that apply and add any that may be missing for them. 7. Briefly review Tapes & Counters from Basics and have the participants complete the assignment in the workbook. 8. Discuss each participants completed assignment in the group. 9. Assign Homework participants are to attempt 100% Zero Access for 1 week. 11 SESSION 2 RELAPSE TRAPS (BEAT THE STREET VIDEO 1) Purpose To assist participants in recognizing that there are classes of rationalizations they use to justify use and to provide cognitive behavioural tools to interrupt the behaviour sequence. Session Objectives 1. Participants will be able to recall at least 5 Relapse Traps and classify them. 2. Participants will be able to self-identify with at least 5 Relapse Traps and provide Counters for each. Introduction In order to maintain abstinence it is critical to understand that there is a variety of using thoughts that precede use. Being able to identify and interrupt this thinking process is crucial to avoiding relapse. 1. Conduct a review of previous sessions (Appendix A). 2. Take up any homework from the last session. 3. Introduce and explain the Beat the Street video series. 4. Prior to playing the video (video 1), explain that you would like them to watch for several key points. List them on the board. relapse traps the lure of easy money the pull of street life handling offers of drugs/alcohol 3. After viewing the video, ask each participant to discuss areas of the video that were most relevant to them. 4. Review and discuss the Relapse Traps in the workbook and ask participants if they can think of any not listed then ask them to classify any they provide according to the categories listed. 5. On the board, review how Tapes and Counters fit into the Behaviour Sequence as taught in Basics. 12 6. Assign homework Participants are to complete the checklist and Tapes & Counters in their workbooks. 13 SESSION 3 REFUSAL SKILLS Purpose To provide participants with a set of skills they can use to effectively refuse offers and/or prevent future offers of drugs or invitations to commit crime. Session Objectives 1. Participants will assess availability of drugs and alcohol and make a list of potential suppliers. 2. Participants will understand some of the possible motivation behind offers of drugs/alcohol or offers to commit crime. 3. Participants will be able to recall the 4 components of effective Refusal Skills. 4. Participants will be able to recall the 3 components of an Assertive Response Style. 5. Participants will be able to demonstrate effective Refusal Skills through role-play. Introduction A major issue for people in recovery is reducing availability of drugs/alcohol and refusing offers of drugs/alcohol and invitations to commit crime. People sometimes feel uncomfortable or guilty about saying no and think they need to make excuses for not using. This can leave the door open for future offers. 1. Conduct a review of previous sessions (Appendix A). 2. Take up any homework from the last session. Assessing Availability 2. Generate a discussion around the questions posed in the workbook: If you wanted to use, how long would it take you to get it? Is there any in your house? Do you still have phone numbers? Do you still have paraphernalia? How many doors have you left open? 3. Have participants complete the list of all persons they are currently involved with who use 14 drugs/alcohol or commit crime. They should use first names only or use pseudonyms if they prefer. Point out that they are just making a list and not being asked to do anything about these relationships. 4. When they have finished their list, generate discussion about their lists are they surprised how many, or how few, people are listed? Is there anything about the categories of relationships that stand out? 5. Explain that the people listed are potential suppliers and make inquires regarding any steps they have already taken to limit availability. Suppliers 6. Explain that supplier motivation is outside of them and not something they have control over. However, it is helpful for them to understand that people can have a variety of reasons for offering them drugs/alcohol or inviting them to commit crimes this section is intended to help them understand that even people who appear to be supportive can be High Risk. 7. Review the possible motivators listed and read aloud the 2 examples to generate discussion. Refusal Skills 8. Explain that many people feel uncomfortable about refusing offers and/or walking away from people offering drugs or offers to commit crime. 9. Explain that No is an answer and does not need to be rationalized or justified. 10. Cover the 4 elements of refusal and the examples listed in the participant workbook. Response Styles 11. Review the Rules for Giving Feedback as taught in Basics. 12. Remind participants that how you say something is as important as what you say. 13. Cover the 3 Response Styles listed in the participant workbook. Tie the information into Colors, as taught in Basics. Practice 14. Introduce role-playing. Since this is the first session that includes formal role-play, it is important to set it up in a way that makes participant feel comfortable. 15 15. Pick a concrete situation that occurred recently for one of the participants. Ask them to provide some background information on the Supplier. 16. Have the participants observing the role-play identify what was done effectively and what was not using the Skill Checklist in their workbook. 17. Do the first role-play twice, with the participant playing the Supplier and the therapist first demonstrating ineffective Refusal Skills and then modeling effective Refusal Skills. 18. Reverse the role for subsequent role-plays and ask for some examples of invitations to commit crime. 16 SESSION 4 SUPPORT SYSTEMS (BEAT THE STREET VIDEO 2) Purpose To encourage participants to develop a Support System of people who are not active drug users, or alcohol abusers, or involved in criminal activity. Session Objectives 1. Participants will identify the strength and quality of their current support system. 2. Participants will make a list of names and phone numbers of people they identify as members of their Support System. Introduction A major challenge for persons new to recovery is to develop a reliable Support Network. An effective Support Network of both formal and informal supports is critical to help deal with the day-to-day stresses of recovery. 1. Conduct a review of previous sessions (Appendix A). 2. Take up any homework from the last session. 3. Prior to playing the Beat the Street video (2), explain that you would like them to watch for several key points. List them on the board. handling triggers and cravings coping with running into getting high buddies and dealers putting together a Support System 3. After viewing the video, ask each participant to discuss areas of the video that were most relevant to them. 4. Have participants complete the Support System table in their workbook emphasize that the people listed must be drug and crime free, and cannot abuse alcohol. 5. When they have finished their list, generate discussion about their lists are they surprised how many, or how few, people are listed? Is there anything about the categories of relationships that stand out? How many are 100% drug, alcohol, crime free? 6. Assign the homework Call or visit every person on your list. 17 Fill in any missing phone numbers. Try to add at least one new name and number. List your support system name & numbers in a little black book or on a wallet-sized card. 18 SESSION 5 FAMILY RELATIONSHIPS (BEAT THE STREET VIDEO 3) Purpose To provide participants with Strategies for dealing with dysfunctional family members, avoid the trap of rescuing others, and cope with past guilt of parenting mistakes. Session Objectives 1. Participants will b
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