1 Group Therapy: Objectives for Training in 12 Step Recovery and CBT The objectives of this training are presented in two parts. The first part of the training is an introduction to group therapy. It consist of four general stages of group counseling. This material comes from a course on group counseling that I taught at Ohio University and follows Gerald Corey’s text “Groups, Process and Practice.” The second part of the training consist of a 12-16 week Twelve Step CBT Group covering relevant topics with handouts. PART 1: Introduction to Group Therapy Characteristics of an effective group counselor. Four Stages of Group Process 1. Initial Stage of a Group: - Group characteristics at the initial stage. - Creating trust: Leader and Member Roles. - Identifying and clarifying goals. - Group process concepts at the initial stage. - Helping clients get the most from the group experience. - Leader Issues at the Initial Stage. - Initial Stage: Summary 2. Transition Stage of a Group: - Group Characteristics of the transition stage: - Problem Behaviors and difficult group members. - Interventions for dealing with resistance therapeutically. - Transition Stage: Summary 3. Working Stage of a Group. - Progressing from the transition stage to the working stage. - Characteristics of the working stage. - Group norms and behavior - Contrasts between a working group and a nonworking group - Therapeutic factors that operate in groups - Working Stage: Summary 4. Ending a Group: - Tasks of the Final: Consolidation of Learning. - Termination of the Group Experience. - Evaluation of the group experience. - Final Stage: Summary. 2 PART 2: Topic 1 – Introduction to 12 Step Recovery and CBT. Topic 2 – The CBT Model of Addiction. Topic 3 – Identifying Your Triggers (focused on the “B” of CBT) Topic 4 – Coping with Craving (focused on the “B” of CBT) Topic 5 – Refusal Skills (focused on the “B” of CBT) Topic 6 – Managing Your Mood. Topic 7 – Changing Your Thinking (focused on the “C” of CBT) Topic 8 – Changing Your Core Beliefs (focused on the “C” of CBT) Topic 9. – Managing Anger (focused on the “C” of CBT) Topic 10 – Developing an All Purpose Coping Plan Topic 11 – Relapse Prevention Topic 12 – Step Review. 3 Introduction to Group Therapy. Characteristics of an effective group counselor. Spirituality is an essential quality of an effective group counselor. Since spirituality is the foundation of recovery it is important for group leaders to make progress in their own spiritual life. You cannot give what you do not have. Courage is demonstrated through your willingness to … - be vulnerable at times, admit mistakes and imperfections. - confront others by to stay “with” them through the confrontation. - act on your beliefs and hunches (which are based on your clinical judgment). - be emotionally touched by others and to identify with others. - examine your own life. - be direct and honest. - express your fears and expectations about the group process. Willingness to model is one of the best ways to teach desired behaviors. The effective group counselor models … - behavior. - attitudes. - openness. - seriousness of purpose. - acceptance of others. - the willingness to take risks. Presence is the ability to be emotionally present with group members. It involves being touched by others’ pain, struggles, and joys. Goodwill and caring is demonstrated by showing sincere interest in the welfare of others. It implies that you will not exploit or use group members to enhance your own ego. Your main job is to help members achieve their goals. Belief in the group process is essential. Effective group counselors have a deep confidence in the value of group process. Faith in the group process leads to constructive outcomes. Openness with yourself and others is a fundamental quality of an effective group counselor. Openness does not mean that you reveal everything you have experienced. Self-disclosure must be use judiciously. Openness means that you are open to group members, open to new experiences, and open to values that differ from your own. 4 Becoming aware of your own culture enables you to understand yourself and others. Knowing how you own culture influences your decisions and daily behaviors provides a frame of reference for understanding the worldview of those who differ from you. Non-defensiveness in coping with attacks allows you to deal with criticism. You cannot afford to have a fragile ego. Group leaders who are insecure, easily threatened, overly sensitive to negative feedback and who depend on group approval will encounter major problems. Stamina refers to your ability to endure. Leading recovery groups can be taxing and draining. You need physical and psychological stamina and the ability to withstand pressure to remain vitalized throughout the process of group. Self awareness is a central characteristic for an effective group leader. You need an awareness of self including your identity, cultural perspectives, goals, motivations, needs, limitations, strengths, values, feelings and problems. Sense of humor is important because, at times, humor can facilitate insight and growth. It also enables clients to enjoy the process and gain new perspectives. Creativity is the capacity to be spontaneous, inventive and fresh. Using your creative can facilitate growth in yourself and your clients. Personal dedication and commitment to improve your clinical skills in leading group is an essential for every group leader. Leaders are learners. They are dedicated and committed to improving their skills. 5 Necessary Group Leadership Skills Empathic listening involves listening to the content and feeling of what is being said. Seek first to understand then to be understood. Most people do not listen with the intent to understand. They listen with the intent to reply. So most of their energy is channeled into talking, not listening. Below are five levels of listening. - ignoring. - pretend listening. - selective listening. - active listening. - empathic listening. Reflecting is a skill that is dependent on empathic listening. It is the ability to convey the essence of what a client has communicated so that the client feels understood. Clarifying is a skill that enables you to help the client sort out the exact meaning of what he or she is trying to communicate. It is also used to help clients understand the meaning of what you are communicating. Summarizing is a skill that is used to condense concepts or material in a clear and concise manner. This can sometimes be accomplished by listing two or three main points. Facilitating encourages and enhances the group process. The group dynamic is not one way or two-way communication. The process of group is multidimensional and dynamic among group members. Interpreting enables the group leader to offer possible explanations for certain behaviors and symptoms. Questioning is useful if it is not overused. Interrogation seldom leads to productive outcomes. It is best to use Socratic questions that are relevant, thought provoking and meaningful. Linking is a skill that requires insight. Effective group leaders find ways of relating various topics to a theme. Confronting group members is sometimes necessary and helpful because it challenges specific behaviors to be examined and modified. Supporting is appropriate when clients are facing a crisis or when they venture into frightening territory. Supporting clients in the group can lead to constructive outcomes. 6 Blocking is a skill that refers to the responsibility clinicians have to block certain activities of group members such as questioning, probing, gossiping, invasion of another’s privacy, breaking confidence, and so forth. Diagnostic skills involve more than labeling behavior, identifying symptoms, and figuring out what category a client falls into. It involves the ability to educate the client, appraise certain behavior problems and choose appropriate interventions. Modeling is an essential method of demonstrating attitudes, abilities and techniques which relate to positive outcomes. Suggesting options and alternatives can help group members develop an alternative course of action. Evaluating is a crucial skill that helps measure progress toward treatment objectives. Terminating the group refers to a clinician’s ability to … - helping clients transfer what they have learned to their own world. - preparing clients for the problems they may face after the group. - arranging aftercare. - maintaining treatment gains. 7 Initial Stage of a Group: Group characteristics at the initial stage. Initial resistance - Some attitudes that relate to initial resistance include … o I don’t really belong here. o I’m not as bad off as these people. o I’m not going to learn anything. o I’ve been hurt in groups like this before. o I’m only here because the court ordered it. - Some common questions clients may have are … o Will I be accepted or rejected? o Can I really say what I feel? o Will other people judge me? o Am I like other people in here? o Will I look stupid? o What if I’m asked to do something I don’t want to do? Self focus versus focus on others. - Some examples of focusing on others rather than working on self include … o Talking about others outside the group. o Telling stories about particular situations that don’t relate. Creating trust: Leader and Member Roles. Establishing trust is a central task in the initial stage of a group. It is not possible to overemphasize the significance of the leader’s modeling and the attitudes expressed through the leader’s behavior in these early sessions. - The importance of modeling. Ask yourself these questions: o Do I feel energetic? o Do I feel enthusiastic about this group? o Do I trust myself to lead? o Do I inspire confidence in the group process? o Do I understand the concepts I’m teaching? o Do I know how to use the techniques I’m encouraging others to use? o To what degree do I trust the group members to work effectively with one another? 8 - Attitudes and actions leading to trust. o Attending and listening. o Interest. o Curiosity. o Understanding nonverbal behavior. o Empathy. o Genuineness. o Judicious use of self-disclosure. o Respect. o Caring confrontations. Identifying and clarifying goals. - Some general goals for group members may include … o To work the 12 steps. o To instill hope through the promises of AA. o To maintain sobriety. o To learn refusal skills. o To change dysfunctional thoughts and behavior. o To manage moods. o To improve skills in conflict resolution. o To comply with court orders. o To improve relationships. o To grow spiritually. o To cope with craving. o To improve decision making skills. o To learn to trust self and others. o To increase self-esteem. o To encourage service work. o To improve communication skills. o To prevent relapse. o To support and challenge others. o To become independent and interdependent. o To increase the capacity for empathy. o To confront others with care and concern. o To learn how to ask for what you need or want. o To learn cooperation. o To be linked to a support network e.g., AA. o To improve social skills for career. o To stop domestic violence and improve relationships. o To become more sensitive to the needs and feelings of others. 9 Group process concepts at the initial stage. Group norms – refer to standards of behavior. The following are examples of standards of behavior that are common in many groups. - Members are expected to attend regularly and show up on time. - Members are expected to be personal and share meaningful aspects of themselves through active participation in the group process. - Members are expected to give feedback to one another. - Members are expected to focus on feelings and express them, rather than talking about problems in a detached and intellectual manner. - Members are expected to focus on the here-and-now interactions in group. - Members are expected to bring into the group personal problems and concerns that relate to recovery and be willing to discuss them openly. - Members are expected to provide therapeutic support to other members. - Members will accept challenges and examine their own thoughts, behaviors and feelings with the goal toward constructive change. - Members are expected to follow the norm of listening to understand, rather than thinking of a quick rebuttal and without becoming overly defensive. Group cohesion – refers to a true sense of community or a feeling of belonging. Genuine cohesion typically comes after groups have struggled with conflict, have shared pain, and have committed themselves to taking significant risks. But the foundation of cohesion can begin to take shape during the initial stage. Below are some suggestions for enhancing group cohesion. - Build trust by creating a climate of respect. - Fulfill the purpose of the group. - Expect disruptions and deal with them creatively. - Encourage group members to share meaningful aspects of themselves as it relates to recovery. - Deal with needs as they emerge. Don’t feel obligated to stay strictly with the agenda. - Avoid too much teaching. - Avoid the misuse of psychological jargon. - Invite all members to become active participants, not merely observers. - Cohesion can be built by sharing the leadership role with the group. - Express persistent feelings of boredom, anger, or disappointment with the group. - Deal with conflict openly and work toward a resolution. - Encourage and praise group when progress toward goals is made. - Be willing to work before and after group. 10 Initial Stage: Summary Stage characteristics. The early phase of a group is a time for orientation. At this stage: - Clients test the atmosphere and get acquainted. - They learn what to expect. - Group cohesion and trust is gradually established. - Clients are concerned about whether they will be included or feel excluded. - A central issue is trust versus mistrust. - There are periods of silence and awkwardness which the group leader deals with constructively by allowing the group process to work. - Members are learning the basic attitudes of respect, acceptance, caring, listening and responding – all attitudes that facilitated building trust. Member functions. Early in the course of the group specific member roles and tasks are critical to shaping the group. - Taking active steps to create a trusting climate. - Learning to express feelings and thoughts. - Being willing to express fears, hopes, concerns, reservations, and expectations about the group. - Establishing goals. - Learning the basics of group process. - Being involved to the creation of group norms. Leader functions. The major tasks of group leaders during the initial stage of orientation are: - Teaching general guidelines. - Developing ground rules. - Setting norms. - Assisting group members in expressing their fears and expectations. - Modeling the facilitative dimensions of therapeutic behavior. - Helping the group establish goals. - Providing a flexible structure for the group. - Assessing the needs of the group and leading in such a way that these needs are met. 11 Transition Stage of a Group. Characteristics of the transition stage: Anxiety may arise within individuals or the group itself. Defensiveness and resistance is natural during this stage. Group members need to test the leader and other group members before the group can move from the transition stage to the working stage. Some factors that influence defensiveness and resistance are … o The fear of making a fool of oneself. o The fear of rejection. o The fear of causing more trouble for oneself. o The fear of emptiness and loneliness. o The fear of losing control. o The fear of self-disclosure. - Once members overcome defensiveness and resistance they can develop mature ways of relating in group such as … o Making emotional connections with each other. o Talk is simple and direct. o Hidden agendas are not present. o Openly taking risk. o Feelings are acknowledged and expressed. The struggle for control is common during the transition stage. Some characteristic group behaviors include - Competition. - Rivalry. - Jockeying for position. - Jealousy. - “One-upmanship”. - Challenges to the leadership. - Passive-aggressive behavior. - “You can’t make me” or “I will do it my way” attitudes. - Attention seeking behavior. Conflict at the transition stage is common. It is the avoidance of conflict that makes it destructive. Cohesion within a group typically increases after conflict and anger are recognized, expressed and resolved. Venting feelings is one way of testing the freedom and trustworthiness of the group. 12 Confrontation involves both challenge and support. Below are some guidelines for appropriate and responsible confrontation. - Members and leaders should know why they are confronting. - Confrontations should not be dogmatic statements concerning who or what a person is. - Don’t brand or label group members with a name. - Instead of making global generalizations about a person, focus on specific, observable behaviors. - Show genuine concern. - It is useful for the person doing the confronting to imagine being the recipient of what is being said. - Ask yourself if you are willing to do what you’re asking others to do. The leader‟s reaction to resistance may help or hinder the group. Below are some suggestions for leaders on how to deal with resistance. - Do not dismiss the client as a “problem”. - Express their annoyance and anger without denigrating their character. - Avoid making sarcastic remarks - Educated the members how the group works. - Explain that resistances is sometimes the necessary prerequisite to cohesion. - Be honest with members rather than mystifying the process. - State observations and hunches in a tentative way, as opposed to being dogmatic. - Avoid stereotyping. - Be sensitive and respectful of cultural differences. - Avoid using intimidation. - Avoid retreating when conflict arises. - Do not meet their need or want at the expense of other clients. - Do not take things too personal. - Facilitate a more focused and objective exploration of the problem. - Invite group members to state how they are personally affected by the problematic behaviors of other members while blocking judgments and harsh evaluations. Problem Behaviors from difficult group members may include … - Silence and lack of participation. - Monopolistic behavior. - Storytelling. - Questioning. - Giving advice. - Band-aiding. - Hostile Behavior. - Dependency. 13 - Acting superior. - Socializing. - Intellectualizing. - Emotionalizing. Transition Stage: Summary Transition Stage characteristics: During the transition stage group members are typically: - Concerned about what others think. - Testing the leader and other members to determine how safe the environment is. - Struggling between wanting to play it safe and wanting to risk getting involved. - Experiencing some struggle for control and power and some conflict with other members or the leader. - Observing the leader to determine if she or he is trustworthy. - Learning how to express themselves so that others will listen. Member functions: During the transition stage group member functions include … - Recognizing and expressing any negative reactions. - Respecting one’s own resistances but working with them. - Moving from dependence to independence to interdependence. - Learning how to confront others in a constructive manner. - Being willing to work through conflicts, rather than avoid them. Leader functions. During the transition stage group leader functions include … - Teaching members to the value of recognizing and dealing fully with conflict situations. - Assisting group members to recognize their own patterns of defensiveness. - Teaching members to respect resistance and to work constructively with the many forms it takes. - Providing a model for members by dealing directly and tactfully with conflict. - Avoiding labeling members but learning to understand certain problem behaviors. - Assisting members to become independent and interdependent. - Encouraging members to express reactions that pertain to here-and-now happenings in the group sessions. 14 Working Stage of Group Progressing from the transition stage to the working stage. - There are no arbitrary dividing lines between the phases of a group. - In actual practice there may be considerable overlap. - Some groups never evolve to a working level. Characteristics of the working stage. Group norms and behavior - Members are provided with both support and challenge. - They are reinforce for making behavioral changes. - The leader is free to employ a variety therapeutic strategies. - Members increasingly interact with each other in more direct ways. - Members are less dependent on the leader for direction and there is less eye contact with the leader and more with the members. - Members learn how to deal with control issues, power struggles, and interpersonal conflicts on a deeper level and are able to transfer these skills to other environments outside the group. - A healing capacity develops within the group as members increasingly experience acceptance of who they are. Contrasts between a working group and a nonworking group Working Group Nonworking Group Members trust other members and the Mistrust is evidenced by an undercurrent of leaders, or at least they openly express any unexpressed hostility. Members withhold lack of trust. There is a willingness to take themselves, refusing to express feelings risks by sharing meaningful here-and-now and thoughts. reactions. Goals are clear and specific and are Goals are fuzzy, abstract, and general. determined jointly by the members and the Members have unclear personal goals or no leader. There is a willingness to direct goals at all. group behavior toward realizing these goals. Most members feel a sense of inclusion and Many members feel excluded or cannot excluded members are invited to become identify with other members. Cliques are more active. Communication among most formed that tend to lead to fragmentation. members is open and involves accurate There is a fear of expressing feelings of expression of what is being experienced. being left out. 15 There is a focus on the here and now; and Clients tend to focus on others and not participants talk directly to one another themselves. Storytelling is typical. There is about what they are experiencing. a resistance to dealing with reactions to one another. The leadership functions are shared by the Members lean on the leader for all group; people feel free to initiate activities direction. There are power conflicts among or to suggest exploring particular areas. members as well as between members and the leader. There is a willingness to risk disclosing Clients hold back and are not open. threatening material; people become Disclosure is at a minimum. known. Cohesion is high; there is a close emotional Division exists; people feel distant from bond among group members. each other. Conflict among members or with the leader Conflicts and negative feelings are ignored, is recognized, discussed, and often denied, or avoided. resolved. Members accept responsibility for deciding Members blame others for their personal what action they will take to solve difficulties and aren’t willing to talk action problems. to change. Feedback is given freely and accepted What little feedback is given is rejected without defensiveness. There is a defensively. Feedback is given without care willingness to seriously reflect on the or compassion. accuracy of feedback. Members fell hopeful; they feel that Members feel hopeless. They despair constructive change is possible. because they feel that change is not possible. Confrontation is accepted as a challenge to Confrontation is done in a hostile attacking examine one’s behavior and not as an way; the confronted one feels judged and uncaring attack. rejected. At times the members gang up on a member, using this person as a scapegoat. Communication is clear and direct. Communication is unclear and indirect. Group members use one another as a Group members are interested only in resource and show interest in one another. themselves. There is an awareness of group process, There is an indifference or lack of and members know what makes the group awareness of what is going on within the productive and nonproductive. group, and group dynamics are rarely discussed. Diversity is encouraged, and there is a Conformity is prized, and individual and respect for individual and cultural cultural differences are devalued. differences. Group norms are developed cooperatively Norms are merely imposed by the leader. by members and the leader. Norms are They may not be clear. clear and designed to help the members attain their goals. Group members use out-of-group time to Group members think about group activity work on problems raised in group. very little when they are outside of group. 16 Therapeutic factors that operate in groups - Self-disclosure. - Confrontation. - Feedback. - Cohesion and universality. - Hope. - Willingness to risk and trust. - Caring and acceptance. - Power. - Catharsis. - The cognitive component. - Commitment to change. - Freedom to experiment. - Humor. Working Stage: Summary Stage characteristics. - High level of trust and cohesion. - Communication is open and involves an accurate expression of what is being experienced. - Leadership functions are shared by group members. - There is a willingness to risk discussing threatening material. - Conflict is recognized, dealt with directly and effectively. - Feedback is given freely and considered nondefensively. - Confrontation occurs in a way in which those doing the challenging avoid slapping judgmental labels on others. - Members are willing to work outside the group to achieve behavioral change. - Clients feel supported by the group and are willing to risk new behavior. - Members feel hopeful that they can change if they are willing to take action. Member functions. - Being willing to engage. - Offering feedback - Being open to feedback from others. - Practicing new skills in daily life. - Offering challenge and support to other members. Leader functions. - Continuing to model appropriate behavior, especially caring confrontation, and disclosing ongoing reactions to the group. - Providing a balance between support and confrontation. - Supporting the members’ willingness to take risks and assisting them in carrying this into daily living. - Interpreting the meaning of behavior patterns at the appropriate times. - Translating insight into action. 17 - Encouraging members to practice new skills. - Promoting behaviors that enhance group cohesion. - Further develop group norms. 18 Ending a Group Tasks of the Final: Consolidation of Learning. During the final stage of a group, members need to be asking certain questions like: “What has this experience meant to you?” “How can you use what you’ve learned in daily living?” “Where do we go from here?” Termination of the Group Experience. - Dealing with feelings of separation. - Dealing with unfinished business. - Reviewing the group experience. - Practice of behavioral change. - Ways of carrying learning further. Giving and receiving feedback. Below are some questions that can be used for giving and receiving feedback during the final stage of the group. Members can ask and answer these questions during group. - My hope for you is … - My greatest fear for you is … - I hope that you will seriously consider … - I see you blocking your strengths by … - Some things I hope you will think about doing for yourself are … - Some ways I hope you’d be different with others are … - Some ways for you to stay in recovery are … Final Stage: Summary. Stage characteristics. - Members may express their hopes optimistically. - There may be some sadness. - There may be some anxiety and fear over the reality of separation. - Members may be deciding what course to take. - They may feel a sense of accomplishment. - There will be planning about follow-up. Member functions. - Dealing with their feelings about separation and termination. - Preparing for generalizing their learning for everyday life. - Expressing appreciation and gratitude for the support they have received from group members and leader. - Making decisions and plans for the future. 19 Leader functions. - Assisting members as they deal with feelings about separation and termination. - Preparing members for generalizing their learning for everyday life. - Expressing appreciation and gratitude the growth they have seen in the members. - Evaluating progress. - Helping members make decisions and plans for the future. - Linking members to AA and/or aftercare. 20 Topic 1 – Introduction to 12 Step Recovery and CBT. The 12 Steps 1. We admitted we were powerless over alcohol - that our lives had become unmanageable. 2. Came to believe that a power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong, promptly admitted it. 11. Sought though 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. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs. Discussion: Discuss how these steps can be incorporated into group and individual counseling. You may also read the 12 traditions and process them in group. Possible Discussion Questions Why are these steps read at the beginning of each AA meeting? What role do the 12 steps play in recovery? Why do you have to work each step one at a time? What is a sponsor’s role in relation to the 12 steps? How do you get a sponsor? (Role play asking someone to be a sponsor). How do you feel about asking someone to sponsor you? What should you expect from your sponsor? Why is it important to read the Big Book? Why is it important to attend meetings? What should you expect when you go to meetings? 21 Goals Worksheet Reviewing your goals can strengthen your motivation. The changes I want to make during the next ________ weeks are: The most important reasons why I want to make those changes are: The steps I plan to take in changing are: The ways other people can help me are: Some things that might interfere with my plan are: 22 Topic 2 – The CBT Model of Addiction. The CBT Model of Addiction We think ten times faster than we talk. On the average we talk about 150 words a minute but we think about 1500 words a minute. This inner dialogue is continuous (you are doing it right now). We process information through words, images and memories. There are five components: thoughts, feelings, behavior, physiological reactions, and environment (situation). Each of the five components affects and interacts with the others. Small changes in any one area can lead to changes in the other areas. Thoughts Environment Addiction Feelings Physical Reaction Behavior 23 The CBT Model of Addiction Thoughts Environment Addiction Feelings Behavior Physical Reaction Conceptualizing the Client Who Is Seeking Treatment Environment Several family members and friends abuse alcohol and drugs. Legal trouble. Financial trouble. Divorce and parent-child problems. Problems at work. Thoughts I’m a failure. I am worthless. My life is hopeless. I am rejected. I will never get sober. I may as well be dead. Feelings Depressed, Anxious. Physical Reaction Great deal of time spent in using alcohol and drugs, or recovering from hangovers. Sweating, rapid pulse, insomnia, nausea or vomiting, physical agitation Behavior Great deal of time spent thinking about, acquiring and using alcohol and drugs. Difficulty working; isolating self, crying, anger outburst, suicide attempts 24 The CBT Model of Addiction Thoughts Environment _________ Feelings Behavior Physical Reaction Understanding My Problems Describe the five areas listed below. Environment Thoughts Feelings Physical Reaction Behavior 25 The Belief Hierarchy Situation Emotion Situation Automatic Emotion Thoughts 26 The Belief Hierarchy Situation Automatic Emotion Thoughts Intermediate Beliefs Situation Automatic Emotion Thoughts Intermediate Beliefs Core Beliefs 27 The Belief Hierarchy Core Belief - I am inadequate Core Belief - I am inadequate Intermediate 1. Attitude It’s terrible to be inadequate Beliefs 2. Assumption (positive)If I work extra hard, I can do OK (negative) If I don’t work hard, I fail 3. Rules: I should always do my best I should be great at everything I try 28 The Belief Hierarchy Core Belief - I am inadequate Intermediate 1. Attitude It’s terrible to be inadequate Beliefs 2. Assumption (positive)If I work extra hard, I can do OK (negative) If I don’t work hard, I fail 3. Rules: I should always do my best I should be great at everything I try Automatic Thoughts I can’t do this when depressed This is too hard I’ll never learn this I always fail 29 Topic 3 – Identifying Your Triggers (focused on the “B” of CBT) The therapist may begin with a questions like: “How many group members have ever heard of Pavlov‟s dogs? What do you know about his experiment? What does it mean to you?” Then give a simple explanation like “Pavlov demonstrated that, over time, repeated pairings of one stimulus (e.g., a bell ringing) with another (e.g., the presentation of food) could elicit a reliable response (e.g., a dog salivating).” Use the diagram below to illustrate. You may want to draw the diagram on the board as you teach this concept. The “B” of CBT. Food Salivation Bell with Food Salivation Bell Salivation Check for understanding. Then ask, “How could Pavlov‟s experiment possibly relate to addictive behaviors?” Give them a chance to answer. Then give a simple explanation like “Over time, addictive behavior can become paired with things like money or paraphernalia, particular places (bars, places to buy drugs), particular people (drug- using associates, dealers), times of day or week (after work, weekends), feeling states (lonely, bored), and so on. Eventually, exposure to those cues (or triggers) alone is sufficient to elicit very intense cravings or urges that are often followed by substance abuse.” 30 Craving Substance People Abuse Craving Substance Places Abuse Craving Substance Things Abuse Craving Substance Feelings Abuse Substance Time Craving Abuse After group members understand these basic concepts ask them to identify their triggers. Identify your “triggers” What people are paired with your addiction? ________________________________ What places are paired with your addiction? ________________________________ What things are paired with your addiction? ________________________________ What feelings are paired with your addiction? ________________________________ What times are paired with your addiction? ________________________________ 31 How is addictive behavior reinforced? Instructions for Therapist: The therapist may begin with a questions like: “How is addictive behavior reinforced? Why do you keep using? What are the desired effects?” Give group members a chance to respond. Encourage group discussion among group members. Then give a simple explanation like: “Drug use is reinforcing because it changes the way a person feels (e.g., powerful, energetic, euphoric, stimulated, less depressed), thinks (I can do anything, I can only get through this if I am high), and behaves (less inhibited, more confident).” Therapist should process the diagram below with the group. Help clients personalize the concept by filling in the blanks in the diagram. The therapist can invite group participation by saying: “This diagram illustrates how addictive behaviors are reinforced. Please help me fill in the blanks. Think of the first blank as the „trigger‟ and the second blank as the „desired effect‟. _______ Negative Substance Consequences Abuse _______ If the group becomes stuck in this process you may give them an example. Depressed Substance abuse Euphoria Negative consequences Anger Substance abuse Carefree Negative consequences Tired Substance abuse Stimulated Negative consequences Timid Substance abuse Confident Negative consequences Anxious Substance abuse Calm Negative consequences 32 INSERT FUNCTIONAL ANALYSIS WORKSHEET (LANDSCAPE) 33 Identify Your Triggers This worksheet will help you identify your triggers. Please reflect each major area (Social, environmental, mental, emotional, and spiritual) as you record your answers in writing. Then share your written responses with the group. Social Triggers: Do you typically use alcohol or other drugs when you are alone or with other people? ____________________________________________________________________ Environmental Triggers: Where do you typically use alcohol or other drugs? What situations or circumstances trigger your use? ________________________________________________________ ______________________________________________________________________ Mental Triggers: What thoughts typically trigger your use of alcohol or other drugs? ________________ ______________________________________________________________________ Emotional Triggers: What feelings typically trigger your use of alcohol or other drugs? ________________ ______________________________________________________________________ Spiritual Triggers: How would you describe your spiritual life when you are triggered to use? ___________ ______________________________________________________________________ Other relevant questions: What is your pattern of use (weekends only, every day, binge use)? What has happened to (or within) you before the most recent episodes of abuse? How would you describe its effects on you before, during and after you use? 34 Replacing Addictive Behaviors with Healthy Ones Recovery involves replacing addictive behaviors for healthy ones. Below is a list of healthy behaviors which can be used to replace unhealthy ones. Please identify which behaviors you plan to use by placing a “check” in the corresponding box. Going to AA meetings. Doing service work. Reading the Big Book. Working the Steps. Getting a sponsor. Calling your sponsor. Participating in group. Exercise. Going to church. Practicing good hygiene. Socializing with friends who support your recovery. Going to work. Praying. Gardening or yard work. Cleaning house. Paying bills. Taking care of your children. Attending community activities. Keeping appointments. Continue counseling. Other healthy behaviors? ________________________________________________________________________ ________________________________________________________________________ Create Your Own Motivation by acting “As if”. Don’t wait to be motivated before you do something. Do something and your are likely to become motivated. Act “as if” your are motivated and your motivation may increase, leading to more action. It is easier to act your way into a better way of feeling than to feel your way into a better way of acting. 35 INSERT ACTIVITIES WORKSHEET (LANDSCAPE) 36 37 Topic 4 – Coping with Craving (focused on the “B” of CBT) Teaching Concepts related to Craving Instructions for therapists This section contains CBT concepts related to craving that must be taught by the therapist. The therapist should present the material in a conversational manner. Don’t be overly didactic. Invite group members to participate. Ask questions, invite comments and check understanding. Let it be a collaborative dialogue. Make it simple, concrete and relevant to the group members. Below I have listed and explained how therapists can present the material on craving. The presentation is merely a guide or example. It is not necessary to present the concepts and techniques as I do. Learn the basic concepts and techniques, then present it in a way that is consistent with your own style. 1. How to introduce the topic of craving The therapist may introduce the topic of craving with this simple explanation: “Craving is a common problem for most people in recovery. You may experience episodes of intense craving for alcohol or drugs. The experience can be both mystifying and disturbing if it is not understood and manage effectively. The goals of this session are: To understand craving as you experience it. To understand that craving is a normal and time-limited experience. To learn various coping strategies to help you effectively deal with craving. 2. Questions for group members After the brief introduction the therapist may begin by asking questions like: Describe your own experience of craving? When does it typically happen? How long does it last? What triggers it? What are the similarities and differences in your responses? Try to identify similarities and differences among group members. Group members may identify common triggers like being around people with who use alcohol or drugs, having money or getting paid, certain social situations, and certain mood states, such as anxiety, depression, or joy. They also identify triggers that are unique to themselves. Triggers for craving can be highly idiosyncratic, thus identification of cues should take place in an ongoing way throughout treatment. 38 3. Review Pavlov Review the material on conditioned cues by paraphrasing Pavlov’s dogs. Use concrete and relevant examples that help clients understand and relate the concept of craving to their own experience. You may asked questions like: “Can you identify the personal “bells” that trigger craving alcohol or drugs? Such questions help clients demystify the experience of craving and enable them to identify and tolerate conditioned craving when it occurs. 4. The therapist may ask questions like: What is craving like for you? What is the feeling like? Do you experience any physical sensations? Where in your body do you experience these physical sensations? How strong is it? Does it move or change? Where else does it occur? How long does it last? How bothered are you by craving? How do you try to cope with it? 5. Review the Identifying your Triggers Worksheet As you review the Identifying Triggers Worksheet focus on identifying the craving and cues that have been most problematic in recent weeks. Encourage clients to monitor their craving so that they can identify new, more subtle triggers as they arise. 6. Learning how to Avoiding Cues Help clients understand that the general strategy of "recognizing, avoiding, and coping" is particularly applicable to craving. After triggers have been recognized it is important for clients to avoid them. This may include breaking ties or reducing contact with individuals who use alcohol or drugs, getting rid of paraphernalia, staying out of bars or other places where alcohol or drugs are used, or no longer carrying more money than needed. 7. Learning how to Coping With Craving The therapist may present the following strategies for coping with craving. Present each coping strategy with questions for discussion. Distraction – What activities can you use to distract yourself? Talking about craving – Who can you call? What would you say? 39 Recalling the negative consequences of substance abuse – Can you recall or remember the negative consequences of substance abuse? Can you mentally rehearse these memories during episodes of craving? Using self-talk – What are some self-coping statements you can use during episodes of craving? Can you list five self-coping statements you could use to help you cope with craving? 8. Demonstrate progressive relaxation Therapists should explain how progressive relaxation can be used as an effective way to cope with craving. Therapists may demonstrate this skill by guiding group members through the following exercise. The therapist may begin by saying: The physical sensation of craving can create stress and tension in your body. It‟s important to learn how to relax your body during episodes of craving. Please allow me to guide you through this progressive relaxation exercise. Lean back in your chair and relax your body. Go as limp as you can from head to foot. Let your shoulder blades go slightly flat. Wiggle your feet Shake your arms gently and let your hands rest on your lap. Roll your head back and forth. Now, we are going to relax each part of our body. Let‟s begin with your … : Legs o Flex the muscles of your left leg by raising it 2 inches off the floor. o Point your toes slightly back toward your head. o Hold this position of tension for about 10 seconds (the therapist counts) o Focus on the tension in your legs. o Then, say to yourself: 'Leg, let go. ' At this point, stop flexing it and let the leg drop. o Say to yourself: 'I feel the tension flowing out of my leg ... My leg feels relaxed, warm, heavy ... completely relaxed o Run through the entire procedure again for your right leg. Thighs o Tighten your thigh muscles, as tightly as you can. o Hold this position of tension for about 10 seconds (the therapist counts). o Then release them, saying 'Let go', to yourself. o Be aware of how relaxed your thigh muscles are. Stomach o Do the same procedure twice for your abdominal muscles Back and Neck o Arch your spine, tightening all along it from your tailbone to your neck, and finish by telling it: 'Let go'. 40 Arms and Shoulders o Imagine there is a bar on your lap. o Wrap your hands around and grab the imaginary bar and clench your fists around it as hard as you can. o Flex the muscles in your hands and arms and shoulders. o Hold this position of tension for about 10 seconds (the therapist counts). o Now relax your hands and arms and shoulders soaking up the warm, relaxed feelings, letting the tension flow out. Jaw o Tighten your jaw muscles o Clamping down on you back teeth. o Hold this position of tension for about 10 seconds (the therapist counts). o Now say to yourself 'Let go' and relax. Face o Tighten your facial muscles into a strong grimace . o Hold this position of tension for about 10 seconds (the therapist counts). o Say to yourself “Let go.” o Rest and focus on the relaxing feeling in your face. Entire body o Clench your feet and fists. o Pull your shoulders up. o Tighten your jaw and face. o Now simultaneously flex your entire body o Hold this position of tension for about 10 seconds (the therapist counts). o Then say to yourself, “Let go” o Just let yourself go ... all the way, as much as you can. o Just sit there and feel the tension drain away. o Feel the tension draining out of you. Now, open your eyes. How do you feel? Are you more relaxed? Do you think you could use this exercise? How might this relaxation exercise help you during episodes of craving? Therapist may encourage the clients to use it regularly, even when they are not craving alcohol or drugs. 9. Demonstrate Breathing Exercises To introduce this coping strategy the therapist may say something like: As you know, the physical sensation of craving can create stress and tension in your body. It‟s important to learn how to relax your body during episodes of craving. Another coping skill you can use is breathing exercises. Then give each client the worksheet on the page that follows. 41 Breathing Exercises Breathing exercises can help reduce stress and anxiety. Four different types of breathing exercises are described below. Read each one carefully. If you don’t understand how to use them asked your therapist to demonstrate how they are done. Deep Breathing – Lie on your back. Breathe evenly and gently, focusing your attention on the movement of your stomach. Continue for 10 breaths. The exhalation should be longer than the inhalation. Measuring your breath by your footsteps – Walk slowly down the hall or in the yard or sidewalk. Breathe normally. Determine the length of your breath, the exhalation and inhalation, by the number of your footsteps. Let it be natural. Continue this for a few minutes and stop. Counting your breath – Sit cross-legged on the floor; or sit in a chair with your feet on the floor; or kneel; or lie flat on your back; or take a walk. As you inhale, be aware that “I am inhaling, 1”. When you exhale, be aware that “I am exhaling, 1”. Remember to breathe from your stomach. When beginning the second inhalation, be aware that “I am inhaling, 2.” And slowly exhaling, be aware that “I am exhaling, 2.” Continue on up through 10. After you have reached 10, return to 1. Whenever you lose count return to 1. Continue this for a few minutes and stop. Following your breath while listening to music – Listen to music. Breathe long, light, and even breaths. Follow your breath; be master of it while remaining aware of the movement and sentiments of the music. Do not get lost in the music, but continue to be master of your breath and yourself. Quiet your mind and body. Do this for two pieces of music (or songs) and stop. Which breathing exercise are you willing to try this week? _______________________ When are you going to do your breathing exercise? _____________________________ Share your experience during the next group. 42 10. Explain the Practice Exercises and assign homework The therapist may assign practice exercises such as the Coping with Craving and Urges Worksheet, The Daily Record of Craving. Progressive Relaxation 43 INSERT THE Coping With Cravings and Urges (LANDSCAPE) 44 INSERT THE Daily Record of Craving (Landscape) 45 Topic 5 – Refusal Skills (focused on the “B” of CBT) Managing Availability List sources of alcohol and drugs here and what you'll do to reduce availability (for example, people who might offer you alcohol or other drugs, places you might get it). Source Steps I'll take to reduce availability 46 Refusal Skills Tips for responding to offers of alcohol or other drugs: Say no first. Make direct eye contact. Ask the person to stop offering it. Don't be afraid to set limits. Don't leave the door open to future offers (e.g., not today). People who might offer me What I'll say to them alcohol/drugs A friend I used to use with: A coworker: At a party: 47 Topic 6 – Managing Your Mood. Emotion can be difficult to identify. Below is a list of moods. Although the list is not comprehensive it may help you describe your feelings in more exact terms. Check these lists for the exact nuance to describe your moods and intensity of feelings. Intensity of Feelings HAPPY SAD ANGRY CONFUSED High Elated Depressed Furious Bewildered Excited Disappointed Enraged Trapped Overjoyed Alone Outraged Troubled Thrilled Hurt Aggravated Desperate Exuberant Left out Irate Lost Ecstatic Dejected Seething Fired up Hopeless Delighted Sorrowful Crushed Medium Cheerful Heartbroken Upset Disorganized Up Down Mad Foggy Good Upset Annoyed Misplaced Relieved Distressed Frustrated Disoriented Satisfied Regret Agitated Mixed up Contented Hot Disgusted Mild Glad Unhappy Perturbed Unsure Content Moody Uptight Puzzled Satisfied Blue Dismayed Bothered Pleasant Sorry Put out Uncomfortable Fine Lost Irritated Undecided Mellow Bad Touchy Baffled Pleased Dissatisfied Perplexed Intensity of Feelings AFRAID WEAK STRONG GUILTY High Terrified Helpless Powerful Sorrowful Horrified Hopeless Aggressive Remorseful Scared stiff Beat Gung ho Ashamed Petrified Overwhelmed Potent Unworthy Fearful Impotent Super Worthless Panicky Small Forceful Exhausted Proud Drained Determined Medium Scared Dependent Energetic Sorry Frightened Incapable Capable Lowdown Threatened Lifeless Confident Sneaky Insecure Tired Persuasive Uneasy Rundown Sure Shocked Lazy Insecure Shy Mild Apprehensive Unsatisfied Secure Embarrassed Nervous Under par Durable Worried Shaky Adequate Timid Unsure Able Unsure Soft Capable Anxious Lethargic Inadequate 48 Rating Moods In addition to identifying moods, it is important to learn to rate the intensity of the moods we experience. Rating the intensity of your moods allows you to observe how your moods fluctuate. Rating the intensity of your moods helps alert you to which situations or thoughts are associated with changes in our moods. You can also use changes in emotional intensity to evaluate the effectiveness of strategies your learn in CBT. Rating Your Mood What was the situation? Situation: ________________________________________________________ What did you feel? Mood: ________________________________________ To what degree would you rate the intensity of this feeling? _______________________________________________________________ 0 10 20 30 40 50 60 70 80 90 100 Things to Remember Moods can usually be described in a word. Rating your moods allows you to evaluate their strength and track the fluctuations of your emotional reactions. Identifying specific moods can help you set and track goals. Strong feelings or moods signal that something important is going on in your life. Rating your moods can enable you to choose interventions designed to alleviate particular moods or reduce their intensity. It is important to separate situations, thoughts and moods. 49 Disentangling Thoughts, Feelings, and Situations This exercise will help you better distinguish your thoughts, feelings, and situations. Circle your answer in the right column to indicate if the item in the left column is a thought, feeling, or situation. Depressed Thought Feeling Situation At the bar Thought Feeling Situation I’m crazy Thought Feeling Situation Angry Thought Feeling Situation Irritated Thought Feeling Situation At work Thought Feeling Situation It’s awlful. Thought Feeling Situation At home Thought Feeling Situation I’m good at this Thought Feeling Situation Driving a car Thought Feeling Situation Something terrible happened Thought Feeling Situation Nothing ever goes right Thought Feeling Situation In the garage Thought Feeling Situation Discouraged Thought Feeling Situation I can’t stand this Thought Feeling Situation Sitting alone Thought Feeling Situation Furious Thought Feeling Situation I’m a failure Thought Feeling Situation Talking on the phone Thought Feeling Situation Panic Thought Feeling Situation She is being inconsiderate Thought Feeling Situation I’m a loser Thought Feeling Situation Guilty Thought Feeling Situation Drinking and driving Thought Feeling Situation At a friend’s house Thought Feeling Situation I’m having a heart attack Thought Feeling Situation He took advantage of me Thought Feeling Situation Anxious Thought Feeling Situation In bed trying to get to sleep Thought Feeling Situation I’m going to loose everthing Thought Feeling Situation I’m in trouble Thought Feeling Situation Thrilled Thought Feeling Situation I hate my life Thought Feeling Situation I have to get sober Thought Feeling Situation Sad Thought Feeling Situation Sitting in an AA meeting Thought Feeling Situation I always work hard Thought Feeling Situation I’m lazy Thought Feeling Situation Panic Thought Feeling Situation In the office Thought Feeling Situation 50 Daily Mood Log Situation Mood 51 Topic 7 – Changing Your Thinking (focused on the “C” of CBT) Examples of Dysfunctional Thoughts About self I am a total failure I should never be afraid I always mess up. I will not be able to stay sober. I am the worst example on earth. I never follow directions. I am so stupid. I can’t solve problems. I should be perfect. About others No one cares about anyone else. All men (or women) are dishonest and are never to be trusted. I can control other people. People are out to get whatever they can from you; you always end up being used. People never listen to my point of view. I always get hurt in relationships so I should withdrawal from other people. All people are out for #1. I must be accepted by other people. I have to be on my guard because people always disappointment me. About treatment I don’t need help. All counselors are untrustworthy. All those people who attend AA meetings gossip. I will never be able to work the steps. The people in treatment don’t really want to get sober. I can’t learn new coping skills. It’s impossible for me to attend AA meetings. Counselors are in for the money. I can’t help the way I feel. I will never get sober. I will never be able to maintain sobriety. Counselors don’t like to work with me. 52 53 Ten Common Dysfunctional Beliefs Read the ten common dysfunctional beliefs and identify which beliefs you are most vulnerable to when you are upset by placing a check () in the shaded area. I should be loved and approved by significant others and live up to their expectations. I must be highly competent, adequate, intelligent and achieving before I can me happy. When people act unfairly I should blame them and view them as bad people. It is a terrible catastrophe when I am rejected, treated unfairly, or when things aren’t as I would like them. Since my feelings are caused by external factors, I have little or no ability to control or change them. I should be greatly concerned about dangerous and fearful things and must center my attention on them until the danger has past. I can handle difficulties and responsibilities better by avoiding them than by facing them. People and things should turn out better than they do, and when they don’t I should see them as awful, terrible, etc. My past remains all-important, and must influence my feelings and behavior now because it once did. I can achieve happiness by being passive. 54 Thought Record Situation Thoughts Feelings What happened List five or more thoughts. Identify and rate the Describe any images. intensity of each feeling on a scale of 0-100%. 55 Socratic Questioning 21 Questions to Ask Yourself Before You Get Upset Thought to be Tested ____________________________________________________ 1. Are my thoughts and/or images true and accurate? 2. Are my thoughts and/or images healthy? Are they helpful? 3. What evidence supports my ideas? 4. What evidence does not support my ideas? 5. Are there other more central thoughts and images left unidentified or unevaluated? 6. Have I correctly identified the problem or upsetting event? 7. Do I completely understand the situation or upsetting event? What is known? What remains unknown? 8. What is the worst possible thing that could happen? 9. What is the best thing that could happen? 10. What is the most realistic outcome? 11. What was going through my mind before I started to feel this way? 12. Are there other disturbing circumstances that contribute to my upset emotion? 13. What images or memories do I have about this situation? 14. If it is true, what does it mean about me? my life? my future? 15. Is there an alternative explanation? 16. Am I going to be able to live through this? 17. What is the effect of my believing this thought or imagining this scene? 18. What could be the effect of changing my thinking? 19. What can I do about it? Are their certain aspects about it that are beyond my control? 20. What would I tell a friend if he or she were in the same situation? 21. Can I speak to myself in the same compassionate way I would talk to a friend? 56 Labeling Cognitive Distortions Category Thoughts and Beliefs Magnifying the negative All or nothing thinking Overgeneralizations Mind reading Catastrophic exaggerations Blaming Assuming Shoulds (Musts/oughts) The fairy tale fantasy Mislabeling Unfavorable comparisons Personalizing Fortune telling Perfectionism Making feelings facts Entitlement 57 Topic 8 – Changing Your Core Beliefs (focused on the “C” of CBT) Identifying Core Beliefs Check the core beliefs that you identify with during times of distress. Indicate which core beliefs you are most vulnerable to when you are upset. Helpless Core Belief I am helpless I can’t get sober I am trapped I can’t stay sober I am a failure I can’t be successful I am hopeless I can’t ask for help I am inadequate I can’t work the program I am ineffective I can’t improve my life I am incompetent I can’t change I am defective I can’t work the steps I am useless I can’t trust Unlovable Core Belief I am unlovable I am not good enough I am unlikable I am different I am unattractive I am abandon I am unwanted I am alone I am rejected I am unnecessary I am bad I am hated (by myself) I am uncared for I am hated (by others) I am unworthy I am evil I am worthless I am insignificant Understanding Core Beliefs It is important to understand the following about core beliefs: That it is an idea, not necessarily the truth. That you can believe it strongly, even “feel” it to be true, and yet have it be mostly or entirely untrue. That, as an idea, it can be tested. That it is usually rooted in past events; that it may or may not have been true at the time you first believed it. That it continues to be maintained through the operation of your schemas, in which you readily recognize data that support the core belief while ignoring or discounting data to the contrary. 58 That you and your counselor working together can use a variety of strategies over time to change this idea so that you can view yourself in a more realistic way. Core Belief Record Record evidence that this Core Belief is not 100% true all the time. Dysfunctional Core Belief __________________________________________________ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 59 Modifying Core Beliefs The purpose of this exercise is to modify dysfunctional core beliefs. Please follow the instructions and complete the worksheet. Old Core Belief ________________________________________________________ What’s the most that you’ve believed this? (0-100%) _________________ What’s the most that you’ve believed this? (0-100%) _________________ How much do you believe it right now? (0-100%) _________________ New Belief ____________________________________________________________ How much do you believe it right now? (0-100%) _________________ Evidence to Support the New Belief List five or more reasons you believe it is true. 1. 2. 3. 4. 5. 60 Core Belief Record Record evidence that supports an alternative Core Belief. New Core Belief __________________________________________________ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 61 Core Belief Record Rate Confidence in new Core Belief over time. New Core Belief __________________________________________________ Date Date Date Date Date Date Date Date Date Date 62 Historical Test of New Core Belief To strengthen your new Core Belief review your life history looking for evidence that supports it New Core Belief __________________________________________________ Birth - 2 Age 3 - 5 Age 6 -12 Age 13 - 18 Age 19 - 25 Age 26 - 35 Age 36 - 50 Age 51 - 65 Age 66+ Summary ______________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 63 Core Belief Record Rate Confidence in new Core Belief over time. New Core Belief __________________________________________________ Date Date Date Date Date Date Date Date Date Date 64 Historical Test of New Core Belief To strengthen your new Core Belief review your life history looking for evidence that supports it New Core Belief __________________________________________________ Birth - 2 Age 3 - 5 Age 6 -12 Age 13 - 18 Age 19 - 25 Age 26 - 35 Age 36 - 50 Age 51 - 65 Age 66+ Summary ______________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 65 Topic 9. – Managing Anger (focused on the “C” of CBT) The ABCD Worksheet Activating Event Beliefs Consequent Emotion Dispute “B” Is it true? Is it helpful or healthy? 66 Topic 10 – Developing an All Purpose Coping Plan If I run into a high-risk situation: 1. I will leave or change the situation. Safe places I can go: ______________________________________________________ 2. I will put off the decision to use for 15 minutes. I'll remember that my cravings usually go away in ______ minutes and I've dealt with cravings successfully in the past. 3. I'll distract myself with something I like to do. Good distracters: _________________________________________________________ 4. I'll call my list of emergency numbers: Name:________________________________ Phone #: __________________________ Name:________________________________ Phone #: __________________________ Name:________________________________ Phone #: __________________________ 5. I'll remind myself of my successes to this point: ______________________________ _______________________________________________________________________ 6. I'll challenge my thoughts and beliefs by: ____________________________________ _______________________________________________________________________ 67 Topic 11 – Relapse Prevention Symptoms Leading to Relapse Not attending meetings. Not having or working with a sponsor. Not working the steps. Not mediating. Not praying. Not reading AA material. Not serving. Exhaustion. Dishonesty. Impatience. Anger Conflict in relationships. Depression. Frustration. Self-pity. Cockiness. Complacency. Expecting too much from others. Entitlement. The use of mood-altering chemicals. 68 Topic 12 – Step Review. 1. We admitted we were powerless over alcohol - that our lives had become unmanageable. 2. Came to believe that a power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong, promptly admitted it. 11. Sought though 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. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs. Discussion: Discuss how these steps can be incorporated into group and individual counseling. You may also read the 12 traditions and process them in group. Possible Discussion Questions Why are these steps read at the beginning of each AA meeting? What role do the 12 steps play in recovery? Why do you have to work each step one at a time? What is a sponsor’s role in relation to the 12 steps? How do you get a sponsor? (Role play asking someone to be a sponsor). How do you feel about asking someone to sponsor you? What should you expect from your sponsor? Why is it important to read the Big Book? Why is it important to attend meetings? What should you expect when you go to meetings? 69 References Alcoholics Anonymous: The Big Book: 4th Ed. (2001). Alcoholics Anonymous World Services, Inc. Works Publishing Incr. New York, NY. Beck, J. (1995). Cognitive Therapy: Basics and Beyond. Guildford Press. New York, NY. Burns, D. D. (1999). The Feeling Good Handbook. New York: William Morrow and Co. Carroll, K.M. (1998) A Cognitive-Behavioral Approach: Treating Cocaine Addiction. 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Treating Alcohol 70 Dependence: A Coping Skills Training Guide in the Treatment of Alcoholism. New York: Guilford, 1989. Sinacola, Richards, S. & Peters-Strickland, Timothy. (2006). Basic psychopharmacology for counselors and psychotherapist. Boston, M.A. Allyn and Bacon Publishers. Twelve Steps and Twelve Traditions. Alcoholics Anonymous World Services, Inc. Works Publishing Incr. New York, NY. White, W. & Kurtz E. (2005). The Varieties of Recovery Experience. Chicago, IL. Great Lakes Addiction Technology Transfer Center.