Co-Occurring Disorders

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					Transitional Services for High Risk Offenders with Co-Occurring Disorders




             Co-Occurring Disorders:
 When Mental Health and Substance Abuse Meet




Attachment #8
Solicitation No. 110068DC
         An Important Message to the Clinicians
               Delivering this Program
While examining lessons learned from the Co-Occurring State Initiative Grant (COSIG)
pilot project at ASPC-Tucson, a reoccurring theme/ issue kept arising. It was the theme of
entitlement. Counselors and other staff members voiced the frustration that several of the
COSIG participants had developed an attitude of entitlement regarding the additional
services and perks that participation in the program afforded them. However, it was not
only staff members who made this observation. Some of the community providers and
even some of the inmates participating in the program had noted and commented about
this issue.

After more discussion, it became apparent that, while the program had done a fine job
addressing mental health and substance abuse issues, there was an additional component
that had not been adequately addressed.

The original curriculum did an excellent job of addressing how thinking, feeling and
behavior are linked. But while criminal thinking is mentioned and even briefly addressed
in some earlier modules, the topic was not addressed in a truly comprehensive manner
until Phase IV. It seems to have been a case of too little, too late. For this reason, those
modules have been revised a bit and are included here. Rather than wait to introduce
these concepts, these concepts should be amongst the first concepts addressed in the
group. The clinician will have to utilize his/her judgment as to when to first introduce the
topic. The first few sessions are likely not appropriate, as the group atmosphere will not
have developed and introducing the topic will have participants thinking that this group is
no different from a cognitive restructuring class.

However, neither should the clinician wait until any later than the fourth week of
programming to introduce the topic.

Neither should this topic be limited to one or two sessions. Rather, these criminal
thinking errors and patterns should be introduced and become a regular part of the
group’s vernacular. It is imperative that the clinician become so familiar with these
errors that identifying them becomes almost automatic. (You’ll know you’re there
when you start challenging your own thinking on a regular basis!) Ideally, after several
sessions with the clinician pointing out criminal thinking errors, group members begin to
identify their own and other’s errors.

A great way to ensure that these errors become a part of everyday group thinking and
discussion is to have the participants create posters that illustrate each of the 8 thinking
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error patterns. Hang the posters in the group room and regularly refer to them. Help the
group members to examine how these errors also impact/ interact with their mental
illness and substance abuse.


Group members may have encountered the concept of thinking errors in other classes
and/or groups. Sometimes the labels for the errors may be bit different but essentially the
concepts are the same. As long as they understand the 8 thinking patterns, they will
understand the concepts well enough to apply and utilize them.

Another major change made in the curriculum was to eliminate the statement:

“If some people do not have their handouts with them, you can give
them new ones to quickly do again.”

Setting a standard where the participants are expected to be responsible and come
prepared for group is crucial with this population. That does not mean that the clinician
should be punitive or demeaning towards the group member of they come unprepared.
But coming unprepared for group is a legitimate group discussion topic and the issue
should be addressed rather than ignored. Failure to do so and excusing such behaviors
only perpetuates the problem. If the issue is rooted in criminal thinking, ignoring it and
merely giving another handout strengthens the criminal thinking pattern of Cognitive
Indolence. If the forgetfulness is related to the participant’s mental abilities and
functioning, ignoring it and merely giving another handout fails to teach the participant
any real world coping skills. In the case of the later situation, the clinician and group
should be proactive and assist the participant in finding solutions such as having a
“buddy” remind him before class or creating a group readiness checklist.


The key is to remember that when working with this population there are at least three
issues that intersect and interact with each other: mental illness, substance abuse and
criminal thinking. At no time should the clinician automatically ascribe a behavior to one
of the three without at least examining if perhaps one of the other two elements is really
the root cause. If you aren’t problem solving based on the root cause, you are at best
merely affixing a band aid to the situation and at worst causing further issues.




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Solicitation No. 110068DC
                              GLOBAL MODULE:
                            Criminal Thinking Errors
Say In Your Own Words:

Today we are going to be looking at some errors in thinking, particularly ones
that lead people to commit criminal acts. It is important to realize that these
errors in thinking end up hurting you, because they threaten your freedom. In
fact, these thinking errors led to your criminal behavior, which led to you
getting convicted and sent to prison.

So to keep yourself from getting re-arrested after you get out, the first thing
you have to change is your thinking. Not everyone has all of the criminal
thinking errors all the time. Some people have a lot of them, while others
have just a few.

 It is important for your recovery to be honest with yourself and figure out
which thinking errors you use frequently, so you can begin to replace these
thoughts with more realistic and positive ones. What are some errors in
thinking that people in the group have used, which led to criminal behavior?

      Solicit answers, and then give out handout “How often do I use these
      Errors in Thinking?”

      Explain how to fill out the table, and then read each line aloud to the
      group, answer questions, and explain and offer examples as needed.
      Then have each person in the group rate themselves on that item.

   Remember that there are no right or wrong answers, only ones that are honest
   or not. Don’t look at how other people are rating themselves, just think about
   how often you use these thinking errors.

   This rating form is just for you, and will be used next group by each person to
   come up with a plan about how to change your thinking. By filling this out
   honestly, you are being honest with yourself in terms of how best to keep
   yourself out of prison in the future.

   If you are not honest in how you fill it out, then you won’t get good
   information, and you will not be able to come up with an effective plan to
   change your thinking and stay out of prison in the future. It is also important
   to realize that sometimes these thoughts are automatic beliefs, and happen so
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   fast that we do not even notice them unless we look very closely.

Handout- Criminal Thinking Errors



These thinking errors can lead to criminal behavior and imprisonment. Write a
number from 1-5 in each of the boxes to the left that shows how often you use
that error in thinking.


         1                     2                   3                  4                 5
                       less than once a   at least once a                        more than once
rarely                                                        daily
                       week               week                                   a day




             No Responsibility-blaming others for my feelings or actions
             Feeling like a victim - I’m getting screwed all the time, I’m getting
             picked on, its not fair
             Feeling entitled- due to past hurts, feeling like the world owes me
             something
             Rebellious- doing the opposite of what I am supposed to do, refusing to
             meet obligations
             Looking out for number one- won’t take other people into account, even
             if they get hurt
             Just this one time- telling myself that I can use just this once or that I'll
             commit one last crime and then I'll stop
             Can’t trust others- others are out to get me, I should get them first; I
             can’t get help

             Loner - feeling different and separated from others, isolating myself

             Rationalizations - false excuses I tell myself to justify my crimes

             Lying - lying to myself and others automatically; lying to protect myself

             Dominating others and putting them down
             Avoiding work/challenges -using the least amount of effort, only doing
             easy/pleasant things


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        Pride- feeling special and better than others, so I don’t have to follow the
        rules




Handout- Criminal Thinking Errors cont.


        Stubborn - I only see things my way, don’t listen to others when they
        don’t agree with me.

        Rigid - won’t change your ideas, not being flexible

        Aimless - no goals, always changing your mind

        Lack of concern or remorse for hurting others
        Impulsive -can’t wait, taking what I want now without considering the
        consequences
        Using drugs - I use drugs so that I am not afraid and/or do not feel guilty
        about committing crimes

        Feeling worthless - it doesn’t matter what I do
        Catastrophizing- making mountains out of molehills, making things
        bigger than they are
        Black-and-White Thinking- seeing things one way or the other, nothing
        in-between

        One way street- won’t give to others but expect them to give to you
        Good Guy- blaming bad actions on good intentions- I stole the money to
        pay my mother's rent
        The "Smart" Criminal- being in prison has taught me so much--next
        time I know how to not get caught!


My most common thinking errors           Counter/ challenge to this thinking




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Say In Your Own Words:

Now that we have examined specific errors in thinking, let’s look at them in a
larger context. Criminal thinking errors tend to fall into 8 large categories.


1. Mollification: Lifestyle criminals seeks to play down the seriousness of past criminal conduct
and urgent interpersonal conflicts by blaming problems on external circumstances, making
excuses for their behavior, pointing out unfairness in the world, or de-valuing their victims.

2. Cutoff: With practice, the lifestyle criminal eliminates normal feelings which deter criminal
action through a simple phrase ("forget-it"), image, or musical theme. In some cases the offender
will use drugs or alcohol to cutoff fear, anxiety, guilt, or other common deterrents to criminal
activity.

3. Entitlement: The lifestyle criminal believes that he is entitled to violate the laws of society and
the rights of others by way of an expressed attitude of ownership ("its mine"), privilege ("I’m
above the law"), or by labeling wants as needs ("I needed a new car, expensive clothing, a trip to
Vegas, etc.").

4. Power Orientation: Choosing power and external control over self-discipline and internal
control, lifestyle criminals attempt to exert power and control over others. Consequently, they feel
weak and helpless (zero state) when not in control of a situation. They attempt to alleviate this
feeling by manipulating, intimidating, or physically assaulting others (power thrust).

5. Sentimentality: Like most people, the lifestyle criminal have an interest in being viewed as a
"Nice guy." However, this creates a serious dilemma, given the level of interpersonally intrusive
activity they have engaged in. Consequently, they may perform various "good deeds" with the
intent of cultivating a "Heck of guy" or "Robin Hood" image.

6. Super-optimism: Experience has taught the lifestyle criminals that they get away with most of
their crimes. This leads to a growing sense of overconfidence in which they believe they are
invulnerable, indomitable, and unbeatable. Ironically, this belief leads to their eventual downfall.

7. Cognitive indolence (Mental laziness): As lazy in thought as in behavior, lifestyle criminals
take short-cuts which inevitably lead to failure, low self-evaluation, and poor critical reasoning
skills.

8. Discontinuity: Lifestyle criminals have difficulty maintaining focus over time because of being
easily influenced by events and situation occurring around them. As a result, they have difficulty
following through on initially good intentions.


        As a group, fill out the next handout. Allow some time for discussion
        before giving the “right” answer. By disusing where they think it
        belongs and why they think it belongs there, the participants will gain
        a greater understanding of each error. There may be times when more
        than one answer will fit. That’s okay. The idea is for participants to
        have a good understanding of the 8 broad patterns.


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Solicitation No. 110068DC
Handout- 8 Criminal Thinking Patterns


1. Mollification: Lifestyle criminals seeks to play down the seriousness of past criminal conduct
and urgent interpersonal conflicts by blaming problems on external circumstances, making
excuses for their behavior, pointing out unfairness in the world, or de-valuing their victims.

2. Cutoff: With practice, the lifestyle criminal eliminates normal feelings which deter criminal
action through a simple phrase ("forget-it"), image, or musical theme. In some cases the offender
will use drugs or alcohol to cutoff fear, anxiety, guilt, or other common deterrents to criminal
activity.

3. Entitlement: The lifestyle criminal believes that he is entitled to violate the laws of society and
the rights of others by way of an expressed attitude of ownership ("its mine"), privilege ("I’m
above the law"), or by labeling wants as needs ("I needed a new car, expensive clothing, a trip to
Vegas, etc.").

4. Power Orientation: Choosing power and external control over self-discipline and internal
control, lifestyle criminals attempt to exert power and control over others. Consequently, they feel
weak and helpless (zero state) when not in control of a situation. They attempt to alleviate this
feeling by manipulating, intimidating, or physically assaulting others (power thrust).

5. Sentimentality: Like most people, the lifestyle criminal have an interest in being viewed as a
"Nice guy." However, this creates a serious dilemma, given the level of interpersonally intrusive
activity they have engaged in. Consequently, they may perform various "good deeds" with the
intent of cultivating a "Heck of guy" or "Robin Hood" image.

6. Super-optimism: Experience has taught the lifestyle criminals that they get away with most of
their crimes. This leads to a growing sense of overconfidence in which they believe they are
invulnerable, indomitable, and unbeatable. Ironically, this belief leads to their eventual downfall.

7. Cognitive Indolence (Mental laziness): As lazy in thought as in behavior, lifestyle criminals
take short-cuts which inevitably lead to failure, low self-evaluation, and poor critical reasoning
skills.

8. Discontinuity: Lifestyle criminals have difficulty maintaining focus over time because of being
easily influenced by events and situation occurring around them. As a result, they have difficulty
following through on initially good intentions.




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Solicitation No. 110068DC
Handout- 8 Criminal Thinking Patterns cont.

Match the thinking error to the thinking pattern:


Thinking Error                                                                  Thinking Pattern


No Responsibility-blaming others for my feelings or actions
Feeling like a victim - I’m getting screwed all the time, I’m getting
picked on, its not fair
Feeling entitled- due to past hurts, feeling like the world owes me
something
Rebellious- doing the opposite of what I am supposed to do, refusing to
meet obligations
Looking out for number one- won’t take other people into account, even
if they get hurt
Just this one time- telling myself that I can use just this once or that I'll
commit one last crime and then I'll stop
Can’t trust others- others are out to get me, I should get them first; I
can’t get help

Loner - feeling different and separated from others, isolating myself

Rationalizations - false excuses I tell myself to justify my crimes

Lying - lying to myself and others automatically; lying to protect myself

Dominating others and putting them down
Avoiding work/challenges -using the least amount of effort, only doing
easy/pleasant things
Pride- feeling special and better than others, so I don’t have to follow the
rules
Stubborn - I only see things my way, don’t listen to others when they
don’t agree with me.

Rigid - won’t change your ideas, not being flexible




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Handout- 8 Criminal Thinking Patterns cont.


Thinking Error                                                                Thinking Pattern


Rigid - won’t change your ideas, not being flexible

Aimless - no goals, always changing your mind

Lack of concern or remorse for hurting others
Impulsive -can’t wait, taking what I want now without considering the
consequences
Using drugs - I use drugs so that I am not afraid and/or do not feel guilty
about committing crimes

Feeling worthless - it doesn’t matter what I do
Catastrophizing- making mountains out of molehills, making things
bigger than they are
Black-and-White Thinking- seeing things one way or the other, nothing
in-between

One way street- won’t give to others but expect them to give to you
Good Guy- blaming bad actions on good intentions- I stole the money to
pay my mother's rent
The "Smart" Criminal- being in prison has taught me so much--next
time I know how to not get caught!




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             This program is meant to be delivered over a period of eight months. Groups should meet
             twice a week for 1-2 hours. Each module will take approximately one group to complete but the
             clinician should allow for group variation, as some topics may be processed more quickly than
             others. Groups should be no larger than twelve inmates.


             The clinician is encouraged to utilize a variety of techniques while presenting the information
             in this curriculum. Activities such as role-plays, poster making, collages, etc. will greatly
             enhance the participants’ learning and retention. Creativity and hands on activities for
             participants are strongly encouraged.


              This curriculum is adapted from Dr. Roger Peter’s Working with Offenders who have Co-
              Occurring Mental and Addictive Disorders: A Treatment Curriculum for Corrections -Based
              Programming. Dr. Peter’s curriculum was utilized for the Co-Occurring State Initiative Grant
              Pilot Program at Arizona State Prison Complex-Tucson. This project was funded by the
              Substance Abuse and Mental Health Services Administration (SAMHSA).


             As part of this project, Arizona State University’s Center for Applied Behavioral Health Policy
            (CABHP) conducted a study of the curriculum. This study included focus groups with the
            clinicians who delivered the program and several of the program participants. The
            recommendations offered in this study proved invaluable in adapting and modifying the
            curriculum.


            Changes to the curriculum include:
                       A reduction from 192 modules to 50 modules.
                       Inclusion of summary sheets for each module.
                       Inclusion of several additional handouts and worksheets for group participants.


                                              Table of Contents

             MODULE 1: The Connection Between Substance Use and Mental Health ………….. 3
             MODULE 2: The Complicated Interaction of Two Disorders …………... …………. 17
             MODULE 3: The Effect of Two Disorders Interacting …………... ………………….27
             MODULE 4: Using Drugs to Control Psychiatric Symptoms ……………………… 33
             MODULE 5: Antecedents, Behavior and Consequences …………………………… 39
             MODULE 6: Making a Commitment to Change ……………………………………49

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             MODULE 7: Barriers to Change …………………………………………………...57
             MODULE 8: Thoughts, Feeling and Behavior……………………………………....63


             MODULE 9: Understanding Thoughts, Feeling and Behavior ………………………69
             MODULE 10: Attitudes and Relapse………………………………………………..85
             MODULE 11: What is Depression? ………………………………………………. .91
             MODULE 12: Depression and Substance Abuse ……………………………………97
             MODULE 13: Fear and Anxiety …………………………………………………..101
             MODULE 14: Understanding Posttraumatic Stress Disorder ……………………...109
             MODULE 15: What is Bipolar Disorder? …………………………………………117
             MODULE 16: What is Schizophrenia? ……………………………………………131
             MODULE 17: Distorted Thinking ………………………………………………...149
             MODULE 18: How to Recognize a Problem ………………………………………155
             MODULE 19: Stressful Events ……………………………………………………157
             MODULE 20: Analyzing and Responding to Problems…………………………….161
             MODULE 21: Solving Real Life Issues ………………………………………..…..165
             MODULE 22: Craving Drugs …………………………………………………….171
             MODULE 23: Triggers …………………………………………………..……….175
             MODULE 24: Avoiding Triggers …………………………………………………183
             MODULE 25: Control of Cravings and Urges …………………………………….187
             MODULE 26: Anti-Craving Exercises …………………………………………….191
             MODULE 27: Managing Thoughts of Your Drug of Choice………………………..195
             MODULE 28: Practicing Self-Talk and Coping Thoughts …………………………201
             MODULE 29: What is Relapse Prevention?………………………………………..209
             MODULE 30: Lifestyle Balance …………………………………………………...217
             MODULE 31: Coping with Stress …………………………………………………223
             MODULE 32: Meditation ………………………………………………..………..229
             MODULE 33: High-Risk Situations ………………………………………………..239
             MODULE 34: Relapse Set-Ups ……………………………………………………245
             MODULE 35: Self Monitoring for Signs of Relapse: Substance Abuse……………...251
             MODULE 36: Recognizing Early Signs of Relapse …………………………..…….257
             MODULE 37: Self Assessment of Life Goals………………………………………..263
             MODULE 38: Self Monitoring for Signs of Relapse: Mental Illness…………………269
             MODULE 39: Early Warning Signs of Mental Illness Relapse……………………...275
             MODULE 40: Identifying Early Signs of Criminal Behavior Relapse……………….279
             MODULE 41: High-Risk Situations for Criminal Behavior Relapse…………………285
             MODULE 42: Triggers, Cravings, Urges-Revisited…………………………………289
             MODULE 43: Managing Triggers, Cravings, and Urges………………..…………..293
             MODULE 44: Lapse and Relapses …………………………………………………299
             MODULE 45: Recovery Networks …………………………………………………305
             MODULE 46: Relapse Prevention Plan ……………………………………………309
             MODULE 47: Benefits of Leading a Healthy Lifestyle…… ………………………...315
             MODULE 48: Values Clarification………………………………………………....323
             MODULE 49: Goals for the Next 5 Years …… ………………………..…………...339
             MODULE 50: Envisioning Your Future…………………………………………....345
             APPENDIX A: Table of Contents for Participants’ Handout Packet………….……...351




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                                           MODULE1:
                        The Connection Between Substance Use and Mental Health?

             DIRECTIONS: Try to make this group interesting to the group members by
             welcoming their input and discussion and using the exercises and discussion
             questions. Present the material in an interactive format. Don’t simply read the
             material. Say it in your own words in a way that you know the participants will
             understand. It may be helpful to review the material prior to presenting it. At that
             time you can underline key points and make notes in the text that you want to
             emphasize to your particular group. In this way, when presenting the material to
             the group, you can reference your notations and focus on making the group session
             more interactive.

             One of the main goals of this module is set the stage for the remaining modules by
             emphasizing the connection between substance use and mental health issues and
             explaining how risk factors and protective factors interact to make one more or less
             likely to experience mental health and substance use issues. Introduce the idea of
             participants completing some of the exercises as homework or with their
             counselors.
             Overview
             A number of factors contribute to whether people develop substance use and
             mental health issues and to how severe these issues may become if they are
             developed. People’s biology (i.e., genetic makeup) and the environments in which they
             live affect their functioning and well-being throughout their lives.

             Biology and Environment:

                            • Interact to create risk factors and protective factors
                            • Exist in different combinations for every person, resulting in
                               greater or lesser chances of experiencing substance use and mental
                               health difficulties and resolving them successfully




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             Biological Factors
             People’s biology can affect how likely they are to develop substance use or mental
             health issues and how severe these issues can become. Biology refers to people’s
             genes that are inherited from their parents at conception. Just like eye color,
             height, and whether people are likely to get certain illnesses such as heart disease,
             people also inherit a tendency toward certain personality traits or ways of thinking,
             feeling, and acting that make them more or less likely to develop substance use and
             mental health issues.

                    Examples of Biological Factors Affecting Mental Health & Substance Use:

                            • Some people may inherit a tendency to become more anxious that
                               most people do, putting them at greater risk for developing
                               anxiety-related mental health problems.

                            • Some people may be biologically predisposed to personality traits
                               or ways of behaving that make it harder for them to stop drinking
                               once they have begun using alcohol.

             People cannot change the genes they inherit from their parents. However, the
             effect that genes have on people’s lives is influenced by the environment. As a
             result, while it is more likely that people will develop difficulties that are similar to those
             of their parents, it is by no means a certainty.



                       • Question 1: Do people have control over their biological risks
                         for developing mental health or substance use problems?

                       •    Answer: No, but they can affect these risks through
                            environmental changes.



             Environmental Factors
             The tendency to develop certain substance use and mental health issues can also be
             affected by the environment in which people live. The environment can be defined
             as the world around us and the effects it has upon us. Where we live, the people
             with whom we come in contact, nutrition, and injuries are all environmental
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             factors. Just as genetic traits vary from person to person, every person experiences a
             unique combination of environmental factors as well.


                     Examples of Environmental Factors Affecting Mental Health & Substance
                     Use:


                             •   Injury to the brain in the womb or during birth
                             •   Exposure to drugs in the womb
                             •   Exposure to toxins in the environment like lead in lead paint
                             •   Nutrition and health while growing up
                             •   Where people live, work, or go to school
                             •   Familial and social relationships

             Environments that are unhealthy or stressful, for whatever the reason, often put people
             at greater risk for developing substance use or mental health difficulties. They can also
             make it more difficult to deal with mental health and substance use issues successfully.




                            Question 2: What are some ways stress could increase the
                            chances someone began using drugs?

                            Answer: A person could use drugs to relax, cope, or
                            improve performance or functioning.


             As the figure below shows, people’s biology and their environments combine to
             influence the ways they think, feel, and behave. This creates risk factors and
             protective factors that in turn have an impact on how likely people are to develop
             substance use and mental health issues and how severe these issues may become if they
             are developed. Risk and protective factors and the ways they affect substance use and
             mental health are discussed next.




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              Module 1 Handout: Relationship


                            Relationship Between Substance Use and Mental Health




                    Biological Factors                     Environmental Factors

                                Risk Factors                           Risk Factors
                      Close biological relative with         Life stressors
                      a disorder                             Relationship issues
                      Personality traits (high risk)         Health & mental health
                      Gender
                      Ethnicity
                                                                   Protective Factors
                            Protective Factors               Coping skills (reduce stress)
                      No family history of substance         Treating substance use & mental
                      use or mental health problems          health problems
                      Adaptive personality traits




                      Substance Use                                  Mental Health




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             Risk Factors

             Just as genetic makeup (biology) and environment vary from person to person, the
             way they interact creates a unique combination of risk factors for individuals.
             Although the genes people inherit are out of their control, it is possible for people to
             take control of the environment and how they deal with that environment.
             Addressing risk factors can reduce chances of developing or worsening substance use
             and mental health issues.


             Biological Risk Factors
             People can inherit from their parents’ genes that make them more or less likely to
             develop substance use or mental health problems. Although the likelihood of
             developing one of these problems if one or both parents have the problem is not
             100%, people whose parents have substance use or mental health problems may be at
             greater risk for developing them themselves. The American Psychiatric
             Association’s Diagnostic and statistical manual of mental disorders, fourth edition
             (1994) provides information regarding the increased risk for developing the mental health
             and substance use problems that will be discussed in this manual. This
             information is summarized in Table 1 below. As can be seen from Table 1, there is an
             increased occurrence of these disorders for individuals who have a first-degree
             biological relative (i.e., close relatives like parents and siblings) with the
             disorder as compared with people in the general population (i.e., who do not have
             first-degree biological relatives with the disorder).
                                                      TABLE 1.

                               DISORDER OF 1ST DEGREE            INCREASED CHANCE
                               RELATIVE                          TO DEVELOP DISORDER
                               (E.G., PARENTS, SIBLINGS)

                               Major Depressive Disorder         1.5 to 3 times more likely to
                                                                 develop Major Depressive
                                                                 Disorder

                               Panic Disorder                    4 to 7 times more likely to
                                                                 develop Panic Disorder

                               Bipolar I Disorder                4% to 24% more likely to
                                                                 develop Bipolar I Disorder



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                              Bipolar I Disorder               4% to 24% more likely to
                                                               develop Major Depressive
                                                               Disorder

                              Schizophrenia                    10 times more likely to
                                                               develop Schizophrenia

             Although the relationship is somewhat less clear for substance use, close relatives
             of people with Alcohol Dependence seem to be 3 to 4 times more likely to develop
             Alcohol Dependence themselves. One example of a biological factor that might
             contribute to risk for developing a substance use problem is differences in brain
             chemistry that make certain people more vulnerable to the effects of drugs or
             alcohol.

             Other biologically influenced characteristics such as personality traits, gender,
             and ethnicity also may affect how susceptible people are to substances of abuse
             and how likely they are to become addicted to them. For example, some
             personality traits such as antisocial personality and sensation seeking are
             associated with increased risk for alcohol and drug problems. Females tend to be
             affected more by alcohol and drugs because of their body size and composition. In
             terms of ethnicity, many people of Asian descent tend to have negative reactions to
             alcohol and, therefore, tend not to drink it as much. As a result, they have reduced
             risk for alcohol problems when compared to other ethnic groups.

             Although it is not possible to choose one’s parents and the genes inherited from
             them, it is important to remember that genes are not everything a person is. People
             may inherit a predisposition to thinking, acting, and feeling certain ways, but it is
             possible that people can change the ways they behave and feel and think.
             Additionally, people can exert a great deal of control over the environments in
             which they live and work, and, as the next section discusses, the environment can
             play a large role in how likely people are to develop mental health and substance
             use issues.




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                       • Question 3: If people cannot change the genes they inherit, how
                       can society expect them to take personal responsibility for treating
                       mental health or substance use problems they may inherit from
                       their parents?

                       • Answer: They still have control over their environmental risk
                         and protective factors. Both greatly affect the extent to which
                         someone suffers from substance use or mental health problems.



             Environmental Risk Factors
             Most often, environmental risks involve some kind of stressor for the individual.
             Stress may include life stressors, the relationships people maintain, and their
             health. Stress can influence how likely it is that people will develop substance use
             and mental health issues. Likewise, substance use and mental health problems can
             become risk factors for each other. In other words, using substances can influence
             mental health, and mental health can influence how likely people are to use
             substances.
             Stress
             In a more general sense, stress can be the result of trying to deal with negative
             things in the environment. When people cannot adapt to stress, they become more
             prone to developing, or making worse, substance use or mental health difficulties,
             particularly if they are also at risk biologically. Types of stress include the
             following:

                            Life stressors:
                            • Work (loss of employment, problems at work, new job)
                            • Moving to a new place
                            • Money (being unable to pay bills or having more money than usual)
                            • Being a victim of a crime
                            • Housing problems (losing one’s home)
                            • Legal problems




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                             Relationships:
                             • Death of a loved one
                             • Divorce, separation, remarrying
                             • Parenting (difficulties raising/caring for one’s children or having
                               unresolved parent/child issues)
                             • Frequent arguments among family members and spouse/significant
                                other
                             • Having few or no friends (lack of social support)
                             • Having friends who use drugs or alcohol
                             • Grief

                            Health and Mental Health:
                             • Illness, injuries, or accidents
                             • Not getting enough rest or eating well
                             • Caring for a sick relative or friend
                             • Not dealing with feelings
                             • Abusing substances
                             • Experiencing mental health symptoms

             An example of a risk factor leading to mental health difficulties is the death of a
             spouse causing someone to feel depressed. It is completely normal to feel
             depressed from time to time, especially after the loss of a loved one. However, as
             will be discussed in upcoming modules, mental health issues that become too
             severe or last longer than is normal can sometimes become mental health problems
             that may require treatment. An example of a risk factor leading to substance abuse
             is drinking to avoid dealing with emotional problems such as feelings of
             depression.


             Protective Factors
             While risk factors make people more prone to experiencing substance use and
             mental health issues, protective factors serve to help buffer or shield people from the
             effects of negative things going on in their lives. As a result, protective factors can help
             prevent or lessen substance use or mental health issues.




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                        Question 4: Give another example of an environmental risk
                        factor leading to mental health difficulties.

                        Question 5: Give another example of an environmental
                        risk factor leading to substance use difficulties.



             Biological Protective Factors
             Just as the genes people inherit from their parents can make them more susceptible
             to mental health and substance use issues, people’s genes can also make them less
             susceptible. Also, people may inherit adaptive personality traits that serve to
             help them “bounce back” faster after depressing events happen to them. Likewise,
             people also could inherit a tendency to deal more successfully with anxiety-
             provoking situations, thus helping to protect them from developing anxiety-related
             disorders.


             Environmental Protective Factors
             There are many beneficial things one can do to reduce the impact of negative life
             circumstances. As described below, protective factors can include actions taken to
             increase coping with life stressors, avoiding substance use, and seeking treatment
             for problematic mental health issues. Just as substance use and mental health
             problems can be risk factors for each other, avoiding substance use and
             maintaining good mental health can help prevent problems in these areas as well.
             Coping Skills
             One category of protective factors involves developing good ways of coping with
             stress and improving overall emotional well-being. In general, coping involves
             creating a supportive and nurturing environment for oneself, developing skills for
             interacting effectively with people, and maintaining a stable living and working
             situation. Good coping mechanisms include:


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                            •   Learning effective communication skills
                            •   Learning problem-solving skills
                            •   Developing a good support system




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                            •     Learning to take responsibility for one’s actions and well-being
                            •     Maintaining employment and a meaningful day-to-day routine
                            •     Participating in recovery/support groups (for substance use
                                  and
                                  mental health problems)
                            •     Practicing relaxation skills and enjoying life

             Treating Substance Use and Mental Health Problems
             As previously discussed, some people may have a biological predisposition toward
             abusing substances while others may be living in environmental circumstances that
             make it more likely they begin to abuse substances. Still other people may have
             both biological and environmental factors that increase the likelihood they will
             become substance abusers.

             Regardless of the causal factors, people can seek treatment from a variety of
             sources. Many times, they will combine two or more treatment modalities to
             increase their chances of breaking their additions. The most common types of
             addiction treatment are listed below:

                            • Individual psychotherapy
                            • Group psychotherapy
                            • Support groups (e.g., AA and NA)

             Once they have become addicted to alcohol or drugs, people often find it very
             difficult to become and remain clean and sober. Many times they become clean
             and sober for a while only to start using again later. This cycle of active addiction
             - recovery - back to active addiction is not uncommon and should not be taken to
             mean that someone cannot stay clean. Instead, someone who has experienced a
             relapse should try to become clean again as soon as possible and restart the
             recovery process. It may take several attempts at becoming and remaining clean,
             but people’s chances of staying clean increase each time they make a wholehearted
             attempt to recover or quit. The old adage is true: practice makes perfect.

             Sometimes people begin experiencing mental health issues that become
             problematic for them. For example, what started out as normal amounts of
             depression or anxiety become larger amounts, or the symptoms last for longer
             periods of time than people normally experience. When this occurs, it may be

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             beneficial for the person to seek treatment. Much like treatment for substance use
             issues, treatment for mental health issues often involves the following:

                            •   Individual psychotherapy
                            •   Group psychotherapy
                            •   Support groups
                            •   Taking medication

             Medications tend to correct chemical imbalances in the brain and are generally not
             addictive, even for addicts. Therapy and support groups help people deal with
             difficult emotions and learn new ways of thinking and acting that improve coping
             with life. One type of therapy that has been shown to be effective in treating
             mental health problems (and substance abuse) is cognitive-behavioral therapy.
             Cognitive-behavioral therapy (CBT) focuses on a client’s thoughts and behaviors.
             Much time is spent in therapy examining and changing inaccurate thoughts the
             client has about himself or herself, about relationships, and about the world in
             general. These inaccurate (or maladaptive) thoughts often lead to or worsen
             mental health issues. Cognitive-behavioral therapy also involves changing the
             behaviors of a client that might be causing problems in his or her life. One
             example of such behavioral change would be to decrease or discontinue
             problematic drug or alcohol use.

             Other types of effective psychotherapy focus on interpersonal relationships,
             understanding difficulties in psychological development clients may have had
             while growing up, and the way relationships with family members affect a client’s life.
             Different therapists may prefer one type of therapy to the others. It is the client’s
             responsibility to “shop around” and find a type of therapy and a therapist with whom he
             or she will be comfortable.

             When seeking help through therapy and support groups, it is important to know
             that they take time to work. People often attend therapy or support groups for
             several months. They also benefit more from treatment if they are honest and work hard
             during treatment.

             Similarly, finding the right medication for a mental health problem involves a
             certain amount of trial and error. Medication that works for one person may not
             work for another, and effective dosages will vary across individuals as well. To be
             effective, most mental health medications also should be taken regularly (or as

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             directed by a physician), not only when one experiences mental health symptoms.
             For example, unless directed by a doctor, people should not stop taking anti-
             depressants as soon as they start feeling less depressed. In summary, the key to
             successful treatment of mental health problems with medication is patience and
             perseverance while finding and taking the right medication and dosage.




                               Question 6: List 3 specific things someone can do to increase
                            his/her protective factors (i.e., increase coping or obtaining help
                            for a substance use or mental health issue).




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                                         Module I Main Points


      Biology and environment can and do interact to create both mental health issues and substance abuse
      disorders.

      Risk factors make you more likely to develop a mental health issue or substance abuse disorder.

      Protective factors help prevent the development of mental health issues or substance abuse
      disorders.

      You want to increase your protective factors and decrease your risk factors.




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                                                 Module 2
                                                MODULE 2:
                               The Complicated Interaction of Two Disorders?

                            The
             Connection Between Substance Use and Mental Health
             People who are experiencing mental health difficulties sometimes self-medicate
             with drugs or alcohol. That is, they turn to substances to help them deal with their
             mental health difficulties. For example, people who experience anxiety make seek
             refuge in alcohol. People may also use drugs to elevate their mood or use drugs or
             alcohol to make them feel mellow and relaxed. However, self-medication is often
             ineffective and can lead to other life and mental health problems such as getting
             into trouble with the law or becoming depressed after repeated use of alcohol to
             calm one’s nerves. The following chart lists various psychoactive (mind affecting)
             substances and their short term and long term effects on the user.


                        Review the following charts with the Group




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              Module 2 Handout: Drug Effects



                                     Effects of Different Psychoactive Substances

             Substance Type   Specific Substances     Long Term Effects of Abuse Short Term Effects of
                                                                                   Abuse

             Alcohol          Beer, wine, “hard         *Alcoholism / unmanageable       *Relaxation, sedation
                              liquor” (E.g., vodka,      life                            *Slowed reaction time
                              scotch, whiskey, gin,     *Increased risk of liver         *Impaired judgment
                              rum, tequila)              disease, brain damage, car      *Loss of inhibition
                                                         accidents, other diseases
                                                        *Risk of death from alcohol
                                                        poisoning
                                                        *Decreased sex drive
                                                        *Impotence
                                                        *Depression
                                                        *Sleep problems


             Cannabis         Marijuana, hashish        *Addiction / unmanageable        *Relaxation
                                                         life                            *Mild euphoria
                                                        *Brain damage                    *Altered sensory
                                                        *Decreased motivation             experiences
                                                        *Difficulty concentrating        *Fatigue
                                                        *Mood swings                     *Anxiety
                                                        *Decreased sex drive             *Panic
                                                        *Impotence                       *Increased appetite
                                                        *Interferes with conception of   *Paranoia
                                                         children


             Stimulants       Cocaine                   *Addiction / unmanageable        *Increased alertness
                              Amphetamines (and          life                             and energy
                              related compounds)        *Unmanageable life               *Decreased appetite
                                                        *Brain damage                    *Positive feelings
                                                        *Difficulty concentrating        *Anxiety
                                                        *Mood swings                     *Tension, feeling
                                                        *Increased risk of fatal heart    jittery, heart racing
                                                         attack or stroke                *Paranoia
                                                        *Increased risk of lung
                                                         disease, other diseases




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                                        Effects of Different Psychoactive Substances
             Substance Type      Specific Substances      Long Term Effects of Abuse Short Term Effects of
                                                                                       Abuse

             Sedatives           Anxiolytic (anxiety        *Addiction                      *Sleepiness
                                 lowering)                  *Risk of death from             *Relaxation
                                 medications (e.g.,          overdose                       *Loss of motor
                                 Xanax, Klonopin,           *Depression                      coordination
                                 Ativan, Valium)            *Decreased motivation           *Loss of inhibition
                                 Barbituates                *Increased risk of HIV/AIDS,    *Dulled sensory
                                                             hepatitis, other diseases       experiences
                                                            *Decreased sex drive
                                                            *Impotence


             Inhalants           Glue                       *Addiction / unmanageable       *Altered perceptions
                                 Aerosols                    life                           *Disorientation
                                 Nitrous oxide              *Severe brain damage
                                 (laughing gas)             *Death, liver/ kidney failure
                                 Freon


             Over-the-counter    Antihistamines and         *Addiction                     *Sedation
             medications         related compounds          *Greatly increased risk of
                                 (e.g., benadryl, other      heart disease, lung diseases,
                                 cold tablets)               all types of cancer, other
                                                             diseases.
                                                            *Increased risk of death
                                                            *Decreased immune function
                                                            *Decreased sex drive
                                                            *Impotence


             Tobacco             Cigarettes                                                 *Alertness
                                 Pipe tobacco                                               *Relaxation
                                 Chewing tobacco
                                 Snuff


             Caffeine            Coffee                                                     *Increased alertness
                                 Tea
                                 Chocolate

             Anti-Parkinsonian   Cogentin, Artane,                                          *Confusion
             Agents              Symmetrel                                                  *Mild euphoria




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             Instead of self-medicating with drugs or alcohol, a more effective way of dealing
             with mental health problem(s) would be to seek counseling, a support group, or
             medications prescribed by a physician. These treatments have more long-lasting
             results and are much safer than abusing drugs or alcohol. For instance, the quality of
             medications is assured by the government, and they have been proven to reduce
             mental health symptoms. On the other hand, drugs bought on the street are often
             from an unknown source, and there is no way to know for sure what is in them or
             what effect they will have on mental health symptoms.

             Sometimes people are afraid of using medication prescribed by physicians to treat
             mental health problems because they worry about becoming addicted to them or
             worry about the side effects. They may also be concerned about the risks of taking
             medications while they are still using drugs or alcohol. Under a physician’s care
             many psychotropic medications (i.e., medications for dealing with mental health
             problems) are very safe and have little risk for addiction. It is important to note,
             however, that use of drugs or alcohol can change how effective these medications
             are. Certain drugs or alcohol may increase the effect of the medications to
             dangerous levels, or they may decrease the effectiveness of the medications to the
             point that taking them has no beneficial effect. While many medications are not
             addictive and do not interact negatively with drugs and alcohol, there are some
             important exceptions. For example, there is the potential for addiction when taking
             benzodiazepines as well as for adverse side effects when they are combined with
             drugs or alcohol. Thus, while most psychotropic medications are safe, that does
             not mean that using drugs or alcohol while on them will not result in negative
             consequences. There is always a risk of adverse consequences for people on
             psychotropic medications who have not successfully abstained from alcohol or
             drugs. As such, when being prescribed medications, it is important to be open and
             honest with your physician about ALL medications you are or may be taking as
             well as the drugs - legal or not - that you are or may be using while on the
             medications.
             Just as mental health problems can be a risk factor contributing to substance use,
             substance use can be a risk factor for mental health problems. In this case,
             however, people who abuse drugs or alcohol may cause or worsen already existing
             mental health problems. One way this can occur is by drugs permanently altering
             brain chemistry. For example, use of marijuana or the designer drug ecstasy can
             make people more likely to experience mood disorders like depression later in life.



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             Other ways that drug and alcohol use can affect mental health is through the added
             life stress that users often experience. Legal problems, family conflict over drug
             use, job loss, and money difficulties are just a few of the ways that drug and
             alcohol use can disrupt people’s lives. These disruptions, just like any other
             stressors, increase the risk of developing or worsening mental health issues.

             To decrease the chances of substance use causing or worsening mental health
             problems, people who abuse alcohol or drugs should seek addiction treatment through
             counseling, support groups, or medication prescribed by a physician. If they are
             experiencing mental health problems in addition to addiction, people can often obtain
             mental health care at the same time.


             Summary
                   People’s biology and the environments in which they live and work interact to
                   make them more or less likely to develop substance use and mental health
                   issues.

                   Biology and environment also affect how severe these issues can become.

                   Specific combinations of biology and environment influence how people
                   think, feel, and act and are called risk factors or protective factors, depending
                   on whether they increase or decrease people’s well-being and functioning.

                   Substance use and mental health issues can be the results of other risk factors and
                   can themselves be risk factors for each other or other problems.

                   Seeking treatment for substance use or mental health problems can reduce
                   people’s risk for further problems and would be considered a protective factor.

                   Effective treatments for substance use and mental health problems include
                   individual and group therapy, support groups, and medication.



             References
                     American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
             Washington, DC: Author.




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              Module 2 Handout: Environment versus Biology

                    1. Imagine that risk factors and protective factors for substance use problems are on
                        competing sides of a scale. Create two scales, one or biological factors and one for
                        environmental factors. For each one, make a list of your risk and protective factors.
                        See which side is heavier (i.e., which side has the greatest number of factors). What
                        does this tell you about your level of risk for substance use problems?




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             2. Which is stronger for you right now, risk or protective factors?

             3. What are some things you can do to reduce your risk factors and enhance your
                protective factors?

             4. Do exercises 1-3 for mental health problems.




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             Assessment of Substance Abuse
             This information is adapted from the DSM-IV (1994) and applies to both alcohol and drug use


             People may meet criteria for substance abuse if their use of alcohol or drugs causes
             significant impairment or distress in their lives in one or more of the following ways
             within a 12-month period.


                 1. Repeated substance use resulting in failure to fulfill major obligations at
                    work, school, or home (e.g., repeated absences or poor work performance
                    related to the substance use; substance-related absences, suspensions, or
                    expulsions from school; neglect of children or household)


                 2. Repeated substance use in situations in which it is physically hazardous
                    (e.g., driving an automobile or operating a machine when impaired by the
                    substance)


                 3. Repeated substance-related legal problems (e.g., arrests for substance-related
                    disorderly conduct)


                 4. Continued substance use despite having persistent or repeating social or
                    interpersonal problems caused or worsened by the effects of the substance
                    (e.g., arguments with spouse about consequences of intoxication, physical
                    fights)




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                                          Module 2 Main Points

      People’s biology and the environments in which they live and work interact to make them
      more or less likely to develop substance use and mental health issues.
      Biology and environment also affect how severe these issues can become.
      Specific combinations of biology and environment influence how people think, feel, and act and
      are called risk factors or protective factors, depending on whether they increase or decrease
      people’s well-being and functioning.

      Substance use and mental health issues can be the results of other risk factors and can
      themselves be risk factors for each other or other problems.

      Seeking treatment for substance use or mental health problems can reduce
      people’s risk for further problems and would be considered a protective factor.

      Effective treatments for substance use and mental health problems include individual and
      group therapy, support groups, and medication.




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                                              MODULE 3:
                              The Effect of Two Disorders Interacting



             Say In Your Own Words:

             Because you have two disorders, the symptoms will interact. Some of the terms
             that are used include exacerbate (which means to make worse), precipitate (to cause
             something to happen) or mask (to cover up the true source). Let's talk about each
             of these for a few minutes.

                        Write the following global categories on an overhead or blackboard

                     “EXACERBATE:” (Overhead)

                      “MARIJUANA...”

             Many research studies have found that persons with (unipolar) depression represent a
             high-risk group for feeling depressed when using even moderate amounts of THC,
             which is the active ingredient in marijuana.

             Some patients said that they had a lot of confusion about 1) who they were
             and what their plans were in life, 2) that they were having a hard time solving
             problems that required them to think logically, 3) that their thoughts didn't seem to be
             flowing and 4) that they felt as if things were unreal.        Have any of these things
             happened to any of you when you were using marijuana?

             Other symptoms that appeared to be getting worse when influenced by
             marijuana were feelings of anxiety, feelings of guilt, and thoughts of suicide. Have
             any of these things happened to anyone while using marijuana?

             Some clients reported that even months after using marijuana they have felt feelings of
             depersonalization (feeling as if they were not real or that they were outside of
             themselves watching what they were doing).




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             Now, this effect is probably not related to specifically being intoxicated,
             months after use, but rather they probably are still feeling this way due to stressors
             in their life. Has anyone felt "depersonalized" after using
             marijuana?

             “COCAINE...”

             Sometimes people who are depressed will use cocaine because they think that it will
             make their mood lighter and happier. While this is the effect that you might be hoping
             will happen, another group of clients were studied and only one-third of them reported
             that they experienced a sense of euphoria. At higher doses, many of them reported that
             they were experiencing a lot of
             intense anxiety and many crying spells.

             “PRECIPITATE”

             One of the issues that we will deal with around your treatment will be
             whether one or the other of your disorders may have caused the other one to occur.
             For most people, but not all, we believe that the symptoms of
             depression occurred before the substance abuse started? What do you think about this?

             Are there symptoms other than those related to depression that you think might
             have lead to your substance abuse?

             The onset of psychotic episodes have been found to be precipitated through drug intake.
             Studies have found a relationship between abusing substances and being admitted to the
             hospital? How do you think these two things might be related? (actively using just prior
             to admission).

             “MASKING”

             Another concern clinicians have is that continued use of substances might be
             hiding a true diagnosis. You probably have heard of Edgar Allen Poe. He
             was a writer that had tremendous mood swings and started drinking a lot in
             an effort to control his moods. What he noticed was that as time went on,
             more and more of his friends thought that his moodiness was related to his
             drinking and forgot that he had had these symptoms long before. Often their




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             symptoms will not understood or even discovered until a person has had a long
             period of non-use.

             “CO-EXIST”

             At one time or another, even if we both agree that your symptoms are very interactive,
             you may feel that symptoms related to one or the other disorder may be present.


             “EXIST INDEPENDENTLY”

             Just like you can have both a broken arm and a broken leg, it is possible,
             though not very likely that you might have two disorders which are not
             interacting ---- though you probably got the broken arm and leg in the same accident!

             “MIMIC”

             Chronic depressant use has been demonstrated to produce an organic
             affective disorder which typically resolves after prolonged abstinence. Both stimulant
             and opiate withdrawal are associated with an organic affective disorder. We will talk
             about this more in another session.

             WHERE IT BEGINS: What is important to remember from all of this is that these
             arrows go both ways (triangular diagram on board with arrows between mental illness
             and substance abuse and criminal behavior) between these
             three experiences.

             CLINICAL EXAMPLE: The Interaction Between Alcohol and Depression

                    Discuss these factors with the clients, listing each on the board as you go
                     along. (From the work of Schuckit, 1986).

             Let's talk a little about the relationship between depression and alcohol abuse. This will
             demonstrate why it is very difficult sometimes to disentangle the relationship between
             these disorders.




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                        Write on the following on the board, if available


             1)     Alcohol can cause depression in any individual

             2)     Signs of temporary serious depression can occur in anyone after a period of
                    prolonged drinking

             3)     Drinking can escalate during a depressive episode

             4)     Symptoms of depression and alcohol abuse occur in the context of other
                    psychological disorders

             5)     For some people, their mood disorders and alcoholism are separate




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                                                Module 3 Main Points

      Theories regarding interaction of substance abuse and mental health:

      Exacerbate- Street drugs make the mental health problem worse.

      Precipitate- One disorder causes the other to occur.

      Masking- Substance abuse disorder “hides’ mental health disorder.

      Co-Exist- Both occur at same time and interact.

      Exist Independently- Both occur at the same time but do not interact.

      Mimic- Substance abuse creates “temporary” symptoms that look like mental health issues.




   Substance Abuse

                                                    Mental Health




                            Criminal Behavior




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                                             MODULE 4:
                            Using Drugs to Control Psychiatric Symptoms



             Say In Your Own Words:

             Has anyone heard of this? What do you think that it means? This is theory
             based on many researchers work over many years time, that proposes that
             substance abuse occurs in an attempt to relieve painful feelings and
             symptoms. Does this make sense to anyone? I'd like to have you take a few
             minutes now to think about when you might have used a substance in an
             attempt to "self-medicate". (Distribute worksheet). When you are finished, we
             will go around the group to discuss what some of your experiences have been.

             CHOOSING DRUGS

             When people choose drugs to alter their mood, they might choose different drugs for
             different reasons. What drugs have people chosen to alter their mood, and what
             effect did you expect it would have?

                     Discuss this at some length; try to bring out misconceptions about how
                     someone thinks that a drug would make them feel and how it did; Be
                     prepared for them to misrepresent these experiences and bring back positive
                     outcomes.

             The problem with using drugs and hoping that they will alleviate your
             symptoms is that that people usually choose drugs that make their symptoms
             worse. That is because most of them do. So while people might be choosing
             drugs that they think will make them feel better, they usually end up feeling
             worse.

             Alcohol, cocaine, marijuana, heroin, and PCP all likely act to produce increased
             symptoms of dysphoria, irritability and anxiety.




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             If the drugs do not produce the effects that people are hoping for, why do they
             continue to use? What do you think about this?
                     Get suggestions from the group; make sure to dispel incorrect assumptions.

             The person who is using drugs to alter their mood recognizes that in small
             doses the drug seems to make them feel better. This prompts them to
             continue to use. Once they have learned this pattern, they continue to practice it but
             also continue to increase the amount that they are drinking or smoking or snorting.
             They also get used to this kind of lifestyle and this behavior
             becomes a bad habit.




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              Module 4 Handout: Why I Used

             Module Handout: Self Medication
             Think about an experience or recent episode when you were using substances that you think
             might have been in an attempt to relieve some painful feelings, or to alter your mood in some
             way. Describe this experience in as much detail as possible.

             I was feeling:




             I took:




             At first, this made me feel:




             After awhile, I felt or experienced:




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             Discussion Topic: Making Decisions and Accepting the Consequences

             Always be clear and consistent with the client about their responsibility for their
             actions.

             Remember, only you are responsible for the decisions that you make. It will
             be our position that you are the only person who can protect you from the
             consequences of your actions. Your family can’t rescue you, just like the staff
             here should not be expected to do that. You make the decisions about what
             you wish to do and the consequences you wish to accept.

                     Open this for discussion.




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                                          Module 4 Main Points



      Self Medicate- This is when a person uses street drugs to treat their mental health issues. Doesn’t work
      very well long term.
         o Often make symptoms worse
         o Wrong type of drug chosen, i.e. marijuana for depression
         o Increased use
         o More problems


      Only you are responsible for the choices you make!




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                                                    MODULE 5:
                                      Antecedents, Behavior and Consequences




             Say In Your Own Words:

             Today I want to talk to you about behavior and how you can analyze, or take a closer
             look at, your behavior. (Use overhead or blackboard, if available) On the overhead
             you will see what we call a simple behavior flowchart.



                    A.      ANTECEDENTS

             1. Every behavior we perform has antecedents and consequences.
             "Antecedent" means something that comes before the behavior. Why are we
             interested in finding out what comes before a certain behavior? Because the
             antecedents that come before a behavior may prompt, or even cause, that behavior to
             happen. If we are to understand a behavior, then, we need to know the antecedents to
             that behavior.

                    B.      BEHAVIOR


             1. Behavior is the action that you take in response to the antecedents. For example,
             someone throws a chair at you—you duck.


                    C. CONSEQUENCES

             1. Many behaviors have both negative and positive consequences. If there are even
             some positive consequences to a behavior, often we will keep repeating the behavior
             despite the negative consequences. Another point - the more
             immediate a consequence, the more power it has. In other words, a
             consequence that is both positive and immediate has a very powerful influence in
             making a behavior happen again.

             2. Consequences may sometimes seem negative but actually be reinforcing. For
             example, Joe feels very uncomfortable around people. Normally, at a
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             party, he would simply sit all by himself and feel awkward. When Joe drinks, though,
             he becomes the "life of the party." Everybody laughs at him and tells him what a fool



             he is. For Joe being made fun of is reinforcing - in other words, it's better than being
             ignored.

             3. The moral of this story is: don't judge a consequence by its appearance. Judge a
             consequence by its effects. If a consequence follows a behavior
             consistently and that behavior continues to occur consistently then it is likely that the
             consequence is reinforcing that behavior.

                    D. ABC EXAMPLES: Distribute handout with this title - See instructor
                    scoring guidelines.

             Let's take some examples of behavior to analyze. I realize that all these
             behaviors and situations may not be familiar in your own lives. I use them on purpose
             so that you know that analysis of behavior has very general use and that you can apply it
             to all kinds of behaviors and situations.

                    Read sequence aloud, analyze on the board listing the antecedents under A,
                 behavior under B, and consequences under C. Discuss whether consequences are
                 negative, reinforcing or both, and indicate with a plus or minus sign.


               Demonstrate the first example and then increasingly use group participation.
               When it appears everyone understands, proceed to the next example. Call on
               members in turn so that everyone has a chance to respond. Where there is
               controversy about whether the behavior is an appropriate response to the
               antecedent stimuli, accept that there are alternative behaviors that might have
               been used.




                    E.      VIGNETTES

             Now let's look at a little more complicated example. Listen carefully, then
             we'll analyze the example. Listen for the antecedents, the behavior, and the
             consequence and try to figure out if the consequence is negative or
             reinforcing.



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                    Distribute page including vignettes #1 and #2 and their corresponding
                  worksheets. Use instructor examples to go through these vignettes with the group.

                     Adapted from: West, H., Dupree, L., & Shonfeld, L. (1988).




                  Module 5 Handout: A B C Examples

             1.      BILL FEELS HUNGRY. HE EATS A PIECE OF FRESH-BAKED PIE. HE FEELS
                     MUCH BETTER.


             2.      MR. JONES SEES HIS FRIEND SITTING ON THE PORCH. HE WALKS ACROSS
                     THE STREET, SITS DOWN AND BEGINS TO TALK. IN A FEW MINUTES HE IS
                     LAUGHING.


             3.      A CAT WALKS UP TO FOUR-YEAR-OLD MARK. HE REACHES OUT AND
                     SQUEEZES THE CAT TOO HARD. THE CAT SCRATCHES MARK.


             4.      BOB'S WIFE COMES HOME FROM WORK, WALKS INTO THE KITCHEN AND
                     SAYS "HELLO!" CHEERFULLY. BOB, WHO IS IN A BAD MOOD, SNAPS AT
                     HER. SHE TURNS AROUND AND QUICKLY LEAVES THE ROOM.


             5.      SIX-YEAR-OLD BILLY FEELS LONELY. HE RUNS AROUND THE HOUSE
                     YELLING AND FALLING DOWN. MOM YELLS AT BILLY. THIS HAPPENS
                     SEVERAL TIMES EVERY DAY.




                     Adapted from: West, H., Dupree, L., & Shoenfeld, L. (1988).

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             Instructor's Scoring Procedures

                   A                         B
             1.    (Bill feels hungry.) (He eats a piece of fresh-baked pie.)
                     C+
                   (He feels much better.)
                         A
             2.    (Mr. Jones sees his friend sitting on the porch.)

                                B
                    (He walks across the street, sits down and begins to talk.)
                             C+
                    (In a few minutes he is laughing.)

                         A
             3.     (A cat walks up to four-year-old Mark.) (He reaches out and

                    B                                 C-
                    squeezes the cat too hard.) (The cat scratches Mark.)

                                    A
             4.     (Bob's wife comes home from work, walks into the kitchen and

                                                    B
                    says "Hello!" cheerfully. Bob who is in a bad mood), (snaps

                                    C-
                    at her.) (She turns around quickly and leaves the room.)

                                   and for Bob's Wife:

                                  A
                    (Bob's wife comes home from work, walks into the kitchen -
                               B                                 C-
                    sees Bob) (and says, "Hello!" cheerfully.) (Bob....snaps at her.)
                           A                                            B


             5.     (Six-year-old Billy feels lonely.) (He runs around the house
                                        C+
                    yelling and falling down.) (Mom yells at Billy.)

             NOTE: We know that Mom's yelling is a reinforcing consequence because the behavior
             continues to happen. In other words, when Billy is lonely, getting yelled at is better than being
             ignored.

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                Module 5 Handout: Vignettes


              (VIGNETTE #1)

             Mr. Smith wakes up on Saturday morning and realizes he has nothing planned to
             do during the day. He feels depressed and lonely. He goes to make a cup of coffee to
             drink while he thinks. When he opens the refrigerator, he sees the beer he
             bought recently for his brother who was visiting. Although he rarely drinks, he gets a
             beer out and opens it. By the time he has finished it, he feels like having another beer.
             By the time he quits, he feels despondent and nauseous.


             (VIGNETTE #2)

             Mr. Smith wakes up on Saturday morning and realizes he has nothing planned to
             do during the day. He feels depressed and lonely. He goes to make a cup of coffee to
             drink while he thinks. When he opens the refrigerator, he sees the beer he
             bought a few months ago for his brother who was visiting. He thinks about
             drinking a beer, but knows it will only result in his feeling worse, so he opens the beers
             and pours them down the sink. Mr. Smith feels stronger and more in control since he
             was able to resist this latest temptation.




             Some material adapted from:
             West, H., Dupree, L., & Schonfeld, L. (1988).




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              Module 5 Handout: Mr. Smith’s Situation




                                                                                NAME   _______________

                                                                                DATE   _______________


                      ABC ASSESSMENT: VIGNETTE #1 (MR. SMITH'S SITUATION)


             1.       WHAT DID MR. SMITH DO? (WHAT IS THE BEHAVIOR WE ARE INTERESTED
                      IN?)




             2.       LIST WHAT PROMPTED MR. SMITH TO DO IT? (LIST ALL ANTECEDENTS)




             3        LIST ALL THE RESULTS (CONSEQUENCES) OF MR. SMITH'S BEHAVIOR.




             4.       INDICATE WHETHER THE CONSEQUENCES ARE POSITIVE (+) OR NEGATIVE
                      (-) OR BOTH (+-) BY PLACING A (+) OR (-) OR (+-) BESIDES EACH
                      CONSEQUENCE LISTED IN NUMBER 3.




             Adapted from: West, H., Dupree, L., & Schonfeld, L. (1988).



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                 ANSWERS: Mrs. Smith’s Situation


             Module 6 Handout: Mrs. Smith’s Situation

                    ABC ASSESSMENT: VIGNETTE #1 (MR. SMITH'S SITUATION)


             1.     WHAT DID MR. SMITH DO? (WHAT IS THE BEHAVIOR WE ARE INTERESTED
                    IN?)

                            He drank three beers.


             2.     LIST WHAT PROMPTED MR. SMITH TO DO IT? LIST ALL ANTECEDENTS.


                            He had no plans for the day.
                            He felt depressed and lonely.
                            He was going to make coffee, but discovered the beer.


             3      LIST ALL THE RESULTS (CONSEQUENCES) OF MR. SMITH'S BEHAVIOR.



                            (-) He felt despondent and nauseous.


              4.    INDICATE WHETHER THE CONSEQUENCES ARE POSITIVE (+) OR NEGATIVE
                    (-) OR BOTH (+-) BY PLACING A (+) OR (-) OR (+-) BESIDES EACH
                    CONSEQUENCE LISTED IN NUMBER 3.




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                  Module 5 Handout: Mrs. Smith’s Situation



             Mod Handout: Mrs. Smith’s Situation
                                                                 NAME_______________

                                                                 DATE_______________


                     ABC ASSESSMENT: VIGNETTE #2 (MR. SMITH'S SITUATION)


             1.      WHAT DID MR. SMITH DO? (WHAT IS THE BEHAVIOR WE ARE INTERESTED
                     IN?)



             2.      LIST WHAT PROMPTED MR. SMITH TO DO IT? LIST ALL ANTECEDENTS.




             3       LIST ALL THE RESULTS (CONSEQUENCES) OF MR. SMITH'S BEHAVIOR.




             4.      INDICATE WHETHER THE CONSEQUENCES ARE POSITIVE (+) OR NEGATIVE
                     (-) OR BOTH (+-) BY PLACING A (+) OR (-) OR (+-) BESIDES EACH
                     CONSEQUENCE LISTED IN NUMBER 3.




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             ANSWERS: Mr. Smith’s Situation Module 6 Handout: Mrs. Smith’s Situation
                                                                               NAME_______________

                                                                               DATE_______________


                    ABC ASSESSMENT: VIGNETTE #2 (MR. SMITH'S SITUATION)


             1.     WHAT DID MR. SMITH DO? (WHAT IS THE BEHAVIOR WE ARE INTERESTED
                    IN?)

                            He discarded the beer.


             2.     LIST WHAT PROMPTED MR. SMITH TO DO IT? LIST ALL ANTECEDENTS.


                            He discovered the beer.
                            He was tempted to drink it.
                            He remembered that when he drinks he ends up feeling worse.



             3      LIST ALL THE RESULTS (CONSEQUENCES) OF MR. SMITH'S BEHAVIOR.


                            (+) He poured out the beer.
                            (-) He felt stronger and more in control.


             4.     INDICATE WHETHER THE CONSEQUENCES ARE POSITIVE (+) OR NEGATIVE
                    (-) OR BOTH (+-) BY PLACING A (+) OR (-) OR (+-) BESIDES EACH
                    CONSEQUENCE LISTED IN NUMBER 3.




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                                                    ule 9

                                          Module 5 Main Points


      Behavior can be looked at has having three main parts- antecedents, actual behavior and consequences

      An antecedent is what comes before the behavior. It can be said to be the cause of the behavior.

      The behavior is the action and response to the antecedent.

      The consequence is the result. Consequences can be good and bad and sometimes it’s
      difficult to tell which it is.



         ANTECEDENT                BEHAVIOR                CONSEQUENCE




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                                                MODULE 6:
                                     Making a Commitment to Change
                                  Making a Commitment to C

              Objectives: 1. To address the role of ambivalence in an individual’s commitment to their
              treatment plan. 2. To evaluate the role of warning signs or cues as risks for relapse.


             Content: Today’s sessions will focus on the topics of motivation, commitment and
             recovery.

             Discussion Topic: Ambivalence

                    Discuss this as a normal part of the recovery

                    process.

             Say In Your Own Words:

             What is ambivalence? (pause for a response). (If none is given, explain this as
             having mixed feelings about doing something). When have you had it? How
             does this fit with trying to abstain from using illicit drugs or alcohol? How is
             this feeling related to decisions that you make about committing crimes? How
             have you demonstrated ambivalence, in any form, through your behavior?

             Could you be ambivalent about addressing your symptoms of depression or
             schizophrenia? If you continue to use, and this worsens your symptoms, does this
             demonstrate your ambivalence about recovering? How has a group
             member "gotten over" their feelings of ambivalence?

             You should use feelings of ambivalence as a signal to stop and re-examine the positive
             and negative consequences of using drugs, committing crimes, or addressing other
             symptoms.




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             Discussion Topic: Motivation

             What does motivation mean to you? (stimulate to action, provide with an
             incentive or motive, impel, incite.) Stop for a moment and consider why you have
             decided to enter this treatment program.

             Was it pressure from family or friends? A strong suggestion from your another
             source? An order from a judge? A particularly unpleasant drug experience like
             crashing?

                    Distribute the motivation worksheet. Ask the clients to list their reasons for
                    changing. Draw the matrix on the board. When clients are done, ask for
                    items to fill this in. Demonstrate which are likely to be the strongest
                    motivators (those that come from within themselves and that they agree with)
                    After each discuss some of the following questions:

              Who feels that they are here to get someone "off of their back"? This is an
             extremely important question.

             Motivation now, and in the future, is really the key to being successful after
             you leave the more intense stages of treatment. You know that you didn't
             begin to feel the way you are feeling over night. It will take you a long time to
             become committed to never using again, stopping yourself from committing
             crimes, and to learning to cope with your symptoms of mental illness.

             Discussion Topic: Commitment

             In this section, we will ask all clients to honestly examine about their level of
             commitment to abstention from drugs and alcohol and treatment of their
             depression.

               Say In Your Own Words:

             How much change is required for you to feel better? What are some of these changes
             (Pause for a response). How committed are you to these changes? How about the
             issue of abstinence for life? How about never committing a crime again? How
             committed do people feel about these issues?

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                    Distribute the Commitment Worksheet. Ask the clients to take a few minutes to
                    fill it out. Discuss factors which strengthen and weaken commitment. Get the
                    group to generate examples. Focus on each clients' factors which weaken
                    his/her commitment. Make sure to share these factors so the group can be
                    aware of the wide range of factors that can weaken commitment. Reinforce
                    each clients' factors which strengthen his/her commitment. Ask if group
                    member's can comment on each other's sources of strength.


             Discussion Topic: Honesty

                    If time remains in the session, do the following exercise:

             Pass out Honesty Worksheet. Help the group see that denial and lie-telling are
             common behaviors when one is addicted, and must be examined as part of
             recovery.

             Have each client complete worksheet and share what he/she has written. Ask them
             which of these they are still using or telling.

             Have group give feedback on responses.




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                Module 6 Handout: Motivation Matrix




             Module 9 Handout: Motivation Matrix
             List your reasons for changing:                                          1 = weak; 5 = strong




             List the reasons why others want you to change:




             Write these in the appropriate box below:

                         WEAKEST MOTIVATOR                          STRONGEST MOTIVATOR

             SOURCE
             Self
                   |______________________|________________________|


             Someone Else
                     |______________________|________________________|

                         1               2                3               4                      5




             Adapted from:
                  Coovert, D.L. (1988). Motivations Worksheet: An interactional model. Unpublished.


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               Module 6 Handout: Commitment


             Module 9 Handout: Commitment
             According to the dictionary to COMMIT is... . "to do, perform or perpetrate, to
             pledge oneself to a position on some issue, to bind or obligate, as by a pledge."

             You cannot change what has already happened to you but you CAN change what
             happens next. Your presence here shows that you've made a COMMITMENT to
             change.

             Abstinence from alcohol and other illicit, non-prescribed drugs and addressing your
             mental health symptoms requires a strong commitment to yourself and the program.
             Agreeing to a lifestyle free from crime also requires a significant
             commitment. We would like you to take a moment to consider the strength of the
             commitment you are making. In the space below consider what is likely to
             strengthen or weaken your commitment to recovery.


             Things that strengthen           Things that weaken
             my commitment                    my commitment

             Example:                         Example:
             My family's support              Thinking about losing friends because I can't party with them


       Things that strengthen my commitment                        Things that weaken my commitment




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             Adapted from: Levy, S., (1988).




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               Module 6 Handout: Honesty
             According to the dictionary the word HONEST means "Not lying, cheating,
             stealing or taking unfair advantage; honorable; truthful; trustworthy. Not
             characterized by deception or fraud; genuine."

             Truth is one of the first "casualties" of an addictive lifestyle. Addicts lie to protect
             and hide their addiction - they lie to others by denying or minimizing their drug use
             and the problems it causes - but worse than that they lie to themselves! Addicts
             wage "psychological warfare" against themselves and the people in their lives who
             matter. The first step in any war is to cease hostilities. This is why all treatment
             programs place the value of HONESTY right up front where it belongs.

             As a first step in practicing personal honesty we want you to deal with the
             DENIAL that has surrounded your use of alcohol and other drugs. Denial is a
             word meaning the lies we tell ourselves to keep from having to admit to ourselves
             we have a problem. In your own words, write down below the lies you tell
             yourself in order to keep on using drugs and alcohol, and think about how this is
             related to your mental health symptoms, or involvement in criminal behavior:
             THE LIES I'VE TOLD MYSELF ABOUT MY USE OF ALCOHOL OR DRUGS:




             THE LIES I'VE TOLD OTHER PEOPLE:




             Adapted from: Levy, S., (1988)




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                                            Module 6 Main Points


      Change is hard and difficult to do.

      People often want to change and don’t want to change at the same time.

      It is easier to change if you are doing for yourself (self motivated), as opposed to doing it for
      other people.

      Change requires commitment.

      Change requires honesty.




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                                               MODULE 7:
                                            Barriers to Change
to Change


             Discussion Topic: Use Warning Signs As A Cue Or Signal For Coping
             Reinforce the idea that any of the warning signs or factors discussed above should be a
             powerful SIGNAL that a coping strategy must be put into action.

             Distribute the handout, "Warning Signs." Go over the handout with the
             group. Ask the group members for personal examples of each of the relapse signs.

             When you've completed coverage of the handout, again remind the group that these
             relapse signs can be used as a signal to apply some appropriate coping
             strategy.




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               Module 7 Handout: Warning Signs

             0 Handout: elapse Signs
             1.     DENIAL: "I can quit anytime I want to" or "I'll just smoke marijuana but I won't do coke
                    anymore."

             2.     OVERCONFIDENCE: "It's all behind me now...there's no chance I'll ever do that again."

             3.     DEFENSIVENESS: "I don't have a real drinking problem - I just happened to get a few
                    DUI's." This is a lot like denial, but with added rationalizations or excuses.

             4.     COMPULSIVENESS: Overworking and/or compulsive about activities and overextending
                    yourself. This is a form of "hiding out" and avoiding dealing with your thoughts about
                    continued abstinence. Just because you're not working on your problems doesn't mean
                    your problems aren't working on you.

             5.     IMPULSIVENESS: Acting without thinking, in many cases a reaction to stress.
                    Impulsive acts can have far-reaching consequences

             6.     LONELINESS: Isolation, avoiding other people, feeling alone. Solution - socialize, call a
                    friend, go to an AA meeting, visit a relative.

             7.     TUNNEL VISION: Looking at only one area of your life. Could be a good area, creating
                    a false sense of well being and security, or a bad area, emphasizing feelings of being
                    treated unfairly by other people and a victim of bad luck. "Once I get off booze, life will be
                    a breeze."

             8.     LACK OF PLANNING: Wishful thinking instead of realistic planning. Life owes you
                    nothing. If you want to "succeed" in life, be prepared to put forth some effort.

             9.     EXCESSIVE ANGER: Periods of anger, frustration and irritability. Is this an "excuse" to
                    use drugs or drink?

             10. "SELLING" SOBRIETY: Trying to hound everybody else to give up drugs/alcohol is
                  often a sign of your own self-doubts. "Sell" yourself. Let others make their own decisions.

             11. WISHFUL THINKING: Hard work is replaced by fantasy. "If I just had a decent job." or
                 "If I just wasn't so behind on my bills." If you want a decent job, do what you need to do to
                 get one (training, apply for a job, do good at the job you now have to establish a good
                 "track record"). If you don't want to be behind on your bills, do something about it (pay
                 them off - remember, you will probably have more money now that you're not spending a
                 fortune on drugs or alcohol; negotiate lower monthly payments). TAKE POSITIVE
                 ACTION - you live your life by DOING.
             Adapted from: T. Gorski (1988)



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             Discussion Topic:     Watching Out For “The Big Three” (Marlatt and Gordon,
             1980).

             Say in Your Own Words:
             A.     Feeling Down. We have been focused all along on what might cause you
                    to relapse once you have committed to an abstinent life-style. The
                    primary reason that most people report as having caused their relapse is their wish
                    to change their negative emotional state. That means they are trying to feel less
                    depressed, sad, bored, frustrated, or angry.

                    Write on the board: “ 1. Feeling Down”

             B.     Fights. Another very common reason for someone relapsing is that they
                    get activated by getting into a fight with someone. This might be with
                    their girlfriend, wife, parent, their boss, a friend or a person at some
                    agency that you are trying to deal with.

                    Write on the board: “2. Fights“

             C.     Going with the Group. Another situation that has been demonstrated to
                    be very dangerous is being around people who are continuing to use or to drink.
                    The pressure that these people exert may be overt --they may directly ask you if
                    you want a drink or joke about you not being able to drink or they may not know
                    that you are trying to abstain. Sometimes this is called peer pressure or social
                    pressure.


                    Write on the board: “ 3. Peer Pressure”



                    Distribute the Handout entitled "The Big Three". Instruct each group member
                    to think about two of the three situations described and to fill in an example
                    from their own experience.




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             Some material adapted from: Dolente, A., Peters, R., and Schonfeld, L., (1990).




               Module 7 Handout: The Big 3

             Module 10 Handout: The Big Three
             Think about your experience with trying not to drink or use. What has happened before in your
             experience? Fill in two of the three examples below.


             Feeling Down: When was the last time you were angry, frustrated, sad, or bored and you ended up
             having a drink/smoke/snort?




             Fights: When was the last time that you felt very angry or upset while having a fight or
             disagreement with someone and you wound up having a drink/smoke/snort?




             Peer Pressure: When did you have a drink/smoke/snort just because everyone else was or
             because someone offered you something, even though you were trying to abstain?




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                                         Module 7 Main Points


      Change does not happen in a straight line. Sometimes we fall back into old behaviors.

      There are some common signs that our change is growing shaky.

      The 3 biggest signs to watch out for are:
        o Feeling down about life and the changes that we made.
        o Fighting with family, friends, and coworkers.
        o Giving in to peer pressure




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                                             MODULE 8:
                                        Thoughts, Feelings, Behaviors

             11

              Objective: 1. To teach the participants the definitions of Thoughts, Feelings and Behaviors.


             Everyone has feelings. We have all felt anger, fear, sadness, happiness and love. We
             experience different feelings, depending on the situation we are in, with whom we
             interact and how we think about the things that happen around us.


             Rationale
             By learning about the basic feelings and their definitions, we can understand
             and, if we choose, change them. Individuals sometimes think they are ‘stuck’ with
             being angry, sad or fearful. By understanding that our thoughts create our emotions
             and then we ‘behave’, (‘thoughts ⇒ feelings ⇒ behavior’) we have an opportunity
             to see where we can interrupt the cycle. For example, I may think “I wanted to
             talk to my sister about how I was doing, but she cut me off. This probably will set
             me up to feel sad. I may stay inside, lay down and not answer the phone
             (behavior) further adding to my sad feeling. I could interrupt this by thinking,
             “Just because she didn’t listen, it doesn’t mean I am not OK”, feeling less
             sadness.. It is by learning that we have choices about how we think, feel and
             behave that helps us take responsibility for ourselves instead of blaming others.




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             Say In Your Own Words:

             Today we are going to define and talk about Thoughts, Feelings and Behavior.

             Our definition for Thoughts = Ideas / messages from the brain

             We think all the time. When we are in the lunch line, we observe the different foods and
             may have a conversation with ourselves about what looks good, the choices we will
             want to make etc. If we take a walk, we may have many
             different ideas and observations about the weather, the color of the sky or
             other people we see. Some other examples of thoughts are: wishes, wants,
             desires, expectations, beliefs, hopes etc.




             Our definition for Feelings (emotions)=Bodily sensations (include physical
             feelings & emotional feelings)

             If we tune into ourselves, we are usually experiencing either a physical or
             emotional feeling.    Examples of physical feelings are: pain, hunger, hot etc.
             Examples of emotional feelings are: fear, love, anger, sad, happy (FLASH).

             It is helpful to first define each feeling, so we can recognize it ourselves and can
             then communicate about it to others:

                     Supply participants with handout –
                     Definitions

             The definition of FEAR = What you feel when you believe you know something is
             going to happen to you (a future expectation /belief) and it is not going to be pleasant.

             The definition of LOVE = What you feel when your only want is to give (a current
             giving expectation/belief)

             The definition of ANGER = What you feel when you do not get what
             you want (an unmet expectation/belief} and you still intend to try and get it

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             The definition of SAD = What you feel when you do not get what you want (an unmet
             expectation/belief} and you have given up hope of ever getting it, even though you
             still want it.

             The definition of HAPPY = What you feel when you get what you want (an
             expectation/belief met)




             Our definition for Behaviors = Actions which can be seen or heard
             “Behavior is anything we can observe other people doing. Some examples
             are: walking, talking, crying, laughing, screaming, sleeping, smiling etc. Our definition
             for Feelings (emotions)=Bodily sensations (include physical feelings & emotional
             feelings)




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                 Module 8 Handout: F.L.A.S.H. (F L A S H)

             •      If we tune into ourselves, we are usually experiencing either a physical or
                    emotional feeling.

             •      Examples of PHYSICAL feelings are: pain, hunger, hot etc.

             •      Examples of EMOTIONAL feelings are: Fear, Love, Anger, Sad, Happy
                    (FLASH)


             The definition of FEAR = What you feel when you believe you know
             something is going to happen to you (a future expectation /belief) and it is
             not going to be pleasant.

             The definition of LOVE = What you feel when your only want is to give
             (a current giving expectation/belief).

             The definition of ANGER = What you feel when you do not get what you
             want (an unmet expectation/belief} and you still intend to try
             and get it.

             The definition of SAD = What you feel when you do not get what you
             want (an unmet expectation/belief} and you have given up hope of ever
             getting it, even though you still want it.

             The definition of HAPPY = What you feel when you get what you want
             (an expectation/belief met).




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                                         Module 8 Main Points


                   THOUGHTS                  FEELINGS              BEHAVIOR



      Everyone has feelings.

      Our feelings can drive our behavior.

      Feelings are often based on what we expect or believe.

      Fear, Love, Anger, Sadness, and Happiness are basic emotions based on different expectations or
      beliefs about people and situations.




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                                                 MODULE 9

                             Understanding Thoughts, Feelings, Behaviors

                        Understanding Thoughts, Emotions, and
            Objective: To practice with participants the definitions of Thoughts, Feelings (emotions) and
            Behaviors.


                        Use the following handouts to lead exercise:
                              “Definition of Feelings (F L A S H), and
                              “Thought, Feeling and Behavior Statements.”

              The leader should use the ‘leader version,’ which gives the correct responses; the
             participant’s version does not have answers for each statement.

             I. Ask group to define whether the underlined word is a thought, feeling or
             behavior (concept). Prompt participants for the definition of each concept.

             II. Ask group members to write one statement (a personal experience) that uses these
             concepts. Ask for volunteers to share with the group and explain definitions for their
             statements.




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              Module 9 Instructor’s version of handout: Thoughts,Feelings,Behavioro Version
             1.     Frank was sad about attending group today. (F)

             2.     Janet gave Frank a hug. (B)

             3.     Terry assumed that everyone would like the game. (T)

             4.     Ruby pointed at the television. (B)

             5.     Randy was happy when he earned a weekend pass. (F)

             6.     John needed to visit his brother. (T)

             7.     Jack was happy that his family was coming to visit this weekend. (F)

             8.     Carl whispered to Joyce, “Don’t worry.” (B)

             9.     Lucy realized that she shouldn’t have yelled. (T)

             10.    Rhonda is painting a picture. (B)

             11.     Margaret’s friends consider the movie to be good. (T)

             12.    Joyce was fearful about meeting with the doctor. (F)

             13.    Dorothy was angry when she had not earned an overnight pass. (F)

             14.    The nurse pushed the medication cart towards the doctor’s office. (B)

             15.    Lucy expects to be able to help people. (T)

             16.    Margaret yelled, “It’s medication time.” (B)

             17.    Brian was amazed at how easily he could hit the target. (T)

             18.    Patrick was fearful about his turn to play the game. (F)

             19.    People often laugh at funny jokes. (B)

             20.    Lisa was sad when she had not received a pay raise. (F)




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             21.    Anna wished the dessert would be chocolate cake. (T)

             22.    Harold and Betty believed that they should attend the group together. (T)

             23.    Suzie smiled when told that she had won the prize. (B)

             24.    Mona was fearful when her picture would not look as nice as Marsha’s. (F)

             25.    Marsha was angry when she ate lunch on the unit. (F)

             26.    Walt drew a picture on the board. (B)

             27.    Mona decided that her picture looked as nice as Marsha’s. (T)

             28.    Some people like to run for exercise. (B)

             29.    Bonnie was happy when she got money in the letter from her mom. (F)

             30.    Allison wondered whether she should go to the movie or not. (T)

             31.    Johnny fantasized about flying a plane. (T)

             32.    Karen was sad to say goodbye. (F)

             33.    Marty is writing a thank you note to Connie. (B)

             34.    Gary winked at me. (B)

             35.    Sammy understood the assignment. (T)

             36.    Judy was sad about the situation. (F)

             37.    Arlene is angry about being broke. (F)

             38.    A lot of people run for exercise. (B)

             39.    Susan believed that he team would win first prize. (T)

             40.    Jason is smoking a cigar. (B)

             41.    Mona was happy when she finished her picture. (F)

             42.    Jim wants to win the game. (T)



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             43.    Mike expected to be in the Intermediate group. (T)

             44.    William is sad that he is staying on the unit. (F)

             45.    Ellen is sitting on the floor. (B)

             46.    Tina’s friends are happy that she can come home. (F)

             47.    Carl and Tim are eating breakfast. (B)

             48.    Burt considered himself a good team player. (T)

             49.    Sally wants to be alone. (T)

             50.    Martha grabbed the beanbag from Scott. (B)

             51.    Sue was sad to have lost the game. (F)

             52.    Sam was happy he won the game. (F)

             53.    Larry is reading a sports magazine. (B)

             54.    Allen hoped he could be the team captain. (T)

             55.    Phyllis wants to have one more turn at the game. (T)

             56.    Ron didn’t get the prize and was angry. (F)

             57.    Agnes is sleeping in the chair. (B)

             58.    Bernie was fearful to ask for a cigarette. (F)

             59.    Wendy was surprised when the fire alarm sounded. (T)

             60.    Mark tossed the beanbag. (B)

             61.    Ed decided that Martha was uncooperative. (T)

             62.    Susan was happy she won the game. (F)

             63.    Burt talked to Ed about the game. (B)

             64.    Abe was sad Mark missed the target. (F)


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             65.    Abe thought Mark would hit the target. (T)




             66.    Sally whispered, “I can’t play this game.” (B)

             67.    Sally wanted to continue the game. (T)

             68.    Sally pitched a beanbag and hit the target. (B)

             69.    Charlie was sad when Sally won the game. (F)

             70.    Mark was angry when he didn’t get another turn. (F)

             71.    Burt considered himself a good player. (T)

             72.    Sally is smiling at Mark. (B)

             73.    Mark kicked the beanbag across the floor. (B)

             74.    Judy guessed that she would lose the game. (T)

             75.    Judy is happy when she was able to play with the others. (F)

             76.    Sally and Charlie were angry when they were told not to play the game. (F)

             77.    Charlie believed that he and Sally should be able to play the game. (T)

             78.    Tom laughed with Charlie. (B)

             79.    Tony yelled at Wanda for missing the target. (B)

             80.    Patrick wished he could go to the mall. (T)

             81.    Martha loves to play cards. (F)

             82.    Roxanne clapped her hands as the movie ended. (B)

             83.    Arlene desires a new dress. (T)

             84.    Mike was fearful about seeing the doctor. (F)

             85.    Greg is sitting in the chair. (B)

             86.    Ben imagined that Kevin would not go to lunch today. (T)
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             87.    Ben was angry when Kevin didn’t show up for lunch. (F)




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             88.    Hilary is juggling tennis balls. (B)

             89.    Peggy decided to go on the picnic. (T)

             90.    Vince was happy Peggy was at the picnic. (F)

             91.    Connie was sad she didn’t pass the test. (F)

             92.    Connie cried after the group. (B)

             93.    Connie believed she would pass the worksheet. (T)

             94.    Stephanie considered the group difficult. (T)

             95.    Margaret is waving good-bye. (B)

             96.    Margaret is sad to be leaving her friends. (F)

             97.    Becky is cooking hamburgers for lunch. (B)

             98.    Jim expects Becky to have lunch with him today. (T)

             99.    Jim is happy about Becky having lunch with him. (F)

             100.   Harold is swimming in the pool. (B)

             101.   John is sad he is sick. (F)

             102.   Harold wanted John to feel better. (T)

             103.   Diane is happy about Fran passing the test. (F)

             104.   Jackie wished she would be able to go home this weekend. (T)

             105.   Tom is walking to the store. (B)

             106.   Jane guessed at the answer to the question. (T)

             107.   Molly laughed at the cartoon. (B)

             108.   Greg was angry when the party was over. (F)

             109.   Larry tripped over the rug. (B)

             110.   Lydia hoped to be elected president. (T)

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             111.   Lydia was happy to be elected secretary. (F)

             112.   Alex is angry about not getting a raise in salary. (F)

             113.   Alex expected a raise in his paycheck. (T)

             114.   Alex ripped up the letter stating he didn’t get a raise. (B)

             115.   Paula has an idea about how to make money for the party. (T)

             116.   Paula is washing cars to make money for the party. (B)

             117.   Tom is happy since Paula is helping to earn money for the party. (F)

             118.   Kelly is writing a poem, on a piece of paper. (B)

             119.   Kelly is fearful that others won’t like her poem. (F)

             120.   Elaine thinks Kelly’s poem is beautiful. (T)

             121.   Sandy grabbed the last balloon. (B)

             122.   Kim is angry she didn’t get a card from her mother. (F)

             123.   Kim expected a card from her mother. (T)

             124.   Frank was sad he missed the concert. (F)

             125.   Marsha is moving the T.V. (B)

             126.   Frank believed he would go to the concert. (T)

             127.   Jack is typing a letter. (B)

             128.   Dick wants to be first in line. (T)

             129.   Dick got angry when he wasn’t first in line. (F)

             130.   Eileen guessed the answer to the question. (T)

             131.   Joe was crying about being late to group. (B)

             132.   Diane was sad when she missed the bus. (F)
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             133.   Peter is painting a picture of a dog. (B)

             134.   Alex is fearful of large dogs. (F)

             135.   Lorie wished she was as good of an artist as Peter. (T)




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               Module 9 Handout: Thoughts,Feelings,Behavioro , Feeling and Behavior
               Statements

             Participants’ Version
             1.     Frank was sad about attending group today.

             2.     Janet gave Frank a hug.

             3.     Terry assumed that everyone would like the game.

             4.     Ruby pointed at the television.

             5.     Randy was happy when he earned a weekend pass.

             6.     John needed to visit his brother.

             7.     Jack was happy that his family was coming to visit this weekend.

             8.     Carl whispered to Joyce, “Don’t worry.”

             9.     Lucy realized that she shouldn’t have yelled.

             10.    Rhonda is painting a picture.

             11.    Margaret’s friends consider the movie to be good.

             12.    Joyce was fearful about meeting with the doctor.

             13.    Dorothy was angry when she had not earned an overnight pass.

             14.    The nurse pushed the medication cart towards the doctor’s office.

             15.    Lucy expects to be able to help people.

             16.    Margaret yelled, “It’s medication time.”

             17.    Brian was amazed at how easily he could hit the target.

             18.    Patrick was fearful about his turn to play the game.

             19.    People often laugh at funny jokes.

             20.    Lisa was sad when she had not received a pay raise.




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               Module 9 Handout: Thoughts,Feelings,Behavioro


             21.    Anna wished the dessert would be chocolate cake.

             22.    Harold and Betty believed that they should attend the group together.

             23.    Suzie smiled when told that she had won the prize.

             24.    Mona was fearful when her picture would not look as nice as Marsha’s.

             25.    Marsha was angry when she ate lunch on the unit.

             26.    Walt drew a picture on the board.

             27.    Mona decided that her picture looked as nice as Marsha’s.

             28.    Some people like to run for exercise.

             29.    Bonnie was happy when she got money in the letter from her mom.

             30.    Allison wondered whether she should go to the movie or not.

             31.    Johnny fantasized about flying a plane.

             32.    Karen was sad to say goodbye.

             33.    Marty is writing a thank you note to Connie.

             34.    Gary winked at me.

             35.    Sammy understood the assignment.

             36.    Judy was sad about the situation.

             37.    Arlene is angry about being broke.

             38.    A lot of people run for exercise.

             39.    Susan believed that he team would win first prize.

             40.    Jason is smoking a cigar.

             41.    Mona was happy when she finished her picture.

             42.    Jim wants to win the game.



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               Module 9 Handout: Thoughts,Feelings,Behavioro


             43.    Mike expected to be in the Intermediate group.

             44.    William is sad that he is staying on the unit.

             45.    Ellen is sitting on the floor.

             46.    Tina’s friends are happy that she can come home.

             47.    Carl and Tim are eating breakfast.

             48.    Burt considered himself a good team player.

             49.    Sally wants to be alone.

             50.    Martha grabbed the beanbag from Scott.

             51.    Sue was sad to have lost the game.

             52.    Sam was happy he won the game.

             53.    Larry is reading a sports magazine.

             54.    Allen hoped he could be the team captain.

             55.    Phyllis wants to have one more turn at the game.

             56.    Ron didn’t get the prize and was angry.

             57.    Agnes is sleeping in the chair.

             58.    Bernie was fearful to ask for a cigarette.

             59.    Wendy was surprised when the fire alarm sounded.

             60.    Mark tossed the beanbag.

             61.    Ed decided that Martha was uncooperative.

             62.    Susan was happy she won the game.

             63.    Burt talked to Ed about the game.

             64.    Abe was sad Mark missed the target.

             65.    Abe thought Mark would hit the target.

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               Module 9 Handout: Thoughts,Feelings,Behavioro


             66.    Sally whispered, “I can’t play this game.”

             67.    Sally wanted to continue the game.

             68.    Sally pitched a beanbag and hit the target.

             69.    Charlie was sad when Sally won the game.

             70.    Mark was angry when he didn’t get another turn.

             71.    Burt considered himself a good player.

             72.    Sally is smiling at Mark.

             73.    Mark kicked the beanbag across the floor.

             74.    Judy guessed that she would lose the game.

             75.    Judy is happy when she was able to play with the others.

             76.    Sally and Charlie were angry when they were told not to play the game.

             77.    Charlie believed that he and Sally should be able to play the game.

             78.    Tom laughed with Charlie.

             79.    Tony yelled at Wanda for missing the target.

             80.    Patrick wished he could go to the mall.

             81.    Martha loves to play cards.

             82.    Roxanne clapped her hands as the movie ended.

             83.    Arlene desires a new dress.

             84.    Mike was fearful about seeing the doctor.

             85.    Greg is sitting in the chair.

             86.    Ben imagined that Kevin would not go to lunch today.

             87.    Ben was angry when Kevin didn’t show up for lunch.



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               Module 9 Handout: Thoughts,Feelings,Behavioro


             88.    Hilary is juggling tennis balls.

             89.    Peggy decided to go on the picnic.

             90.    Vince was happy Peggy was at the picnic.

             91.    Connie was sad she didn’t pass the test.

             92.    Connie cried after the group.

             93.    Connie believed she would pass the worksheet.

             94.    Stephanie considered the group difficult.

             95.    Margaret is waving good-bye.

             96.    Margaret is sad to be leaving her friends.

             97.    Becky is cooking hamburgers for lunch.

             98.    Jim expects Becky to have lunch with him today.

             99.    Jim is happy about Becky having lunch with him.

             100.   Harold is swimming in the pool.

             101.   John is sad he is sick.

             102.   Harold wanted John to feel better.

             103.   Diane is happy about Fran passing the test.

             104.   Jackie wished she would be able to go home this weekend.

             105.   Tom is walking to the store.

             106.   Jane guessed at the answer to the question.

             107.   Molly laughed at the cartoon.

             108.   Greg was angry when the party was over.

             109.   Larry tripped over the rug.

             110.   Lydia hoped to be elected president.

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               Module 9 Handout: Thoughts,Feelings,Behavioro


             111.   Lydia was happy to be elected secretary.

             112.   Alex is angry about not getting a raise in salary.

             113.   Alex expected a raise in his paycheck.

             114.   Alex ripped up the letter stating he didn’t get a raise.

             115.   Paula has an idea about how to make money for the party.

             116.   Paula is washing cars to make money for the party.

             117.   Tom is happy since Paula is helping to earn money for the party.

             118.   Kelly is writing a poem, on a piece of paper.

             119.   Kelly is fearful that others won’t like her poem.

             120.   Elaine thinks Kelly’s poem is beautiful.

             121.   Sandy grabbed the last balloon.

             122.   Kim is angry she didn’t get a card from her mother.

             123.   Kim expected a card from her mother.

             124.   Frank was sad he missed the concert.

             125.   Marsha is moving the T.V.

             126.   Frank believed he would go to the concert.

             127.   Jack is typing a letter.

             128.   Dick wants to be first in line.

             129.   Dick got angry when he wasn’t first in line.

             130.   Eileen guessed the answer to the question.

             131.   Joe was crying about being late to group.

             132.   Diane was sad when she missed the bus.




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               Module 9 Handout: Thoughts,Feelings,Behavioro

             133.   Peter is painting a picture of a dog.

             134.   Alex is fearful of large dogs.

             135.   Lorie wished she was as good of an artist as Peter.




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                                          Module 9 Main Points


      Thoughts, feelings and behaviors are inert-related.

      It is important to know the difference between a thought, a feeling and a behavior.




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                                                  MODULE 10
                                             Attitudes and Relapse

             Objective: To review attitudinal and emotional factors associated with relapse to drug use.


             Content: This session confronts attitudinal and feeling factors that may
             interfere with the individuals’ ability to successfully remain abstinent from alcohol,
             drugs and criminal behaviors.

             Discussion Topic: Relapse Factors and Warning Signs

             Say In Your Own Words:

                 A.     Discuss types of feeling, attitudinal, behavioral, and cognitive
                      factors which could precede a relapse.

                      1.      Negative feeling states:   What are some feelings that might
                            trigger a relapse?

                          a. Feeling bad about yourself, feeling hopeless, loneliness,
                               boredom, anger, frustration, etc.
                          b. Who has heard of the phrase: “Don't ever let yourself get too
                               Hungry/Angry/Lonely/Tired (HALT)”?
                          c. Ask group to come up with personal examples of how negative
                               emotional states have led to use of substances. (Example: When
                               has someone in the group felt bad about themselves and started
                               to use?)
                      You should use negative emotional states, or uncomfortable feelings, as
                      an early warning sign or a cue to come in with a coping strategy, which you
                      have prepared in advance.

                      2. Dangerous attitude: What could be a dangerous attitude for you to
                          hang on to which could effect your treatment? (Give these
                          examples if not generated)




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                            a. Resisting the idea of total abstinence.

                            b. Why me? Overconfidence, defeatist attitudes, resisting taking
                               responsibility for own recovery. Blaming using on something
                               or someone other than you.

                     Ask group to come up with more examples.

                     STRATEGY: Keep repeating to yourself why you need to maintain a total
                     abstinence. Ask treatment personnel to give you feedback when they hear you
                     expressing negative attitudes.

                     3.     Dangerous behavior. What are some dangerous behaviors that you
                            might do? (Give these examples if not generated)

                            a. Hanging around people who are using.

                            b. Going places where there may be cues to use, such as
                               gatherings or parties with users, etc.

                            c. Letting up on recovery-related activities such as therapy, N.A.,
                                etc.

                                  Ask group to come up with more examples of behavior which
                                  could lead to relapse.

                                  Strategy: Try to arrange "safe situations" for yourself, (situations in which
                                  using would be impossible): shopping, church, visiting non-using friends.
                                  (Ask group to come up with more examples.)

                     4.      Dangerous thinking- What have you learned are dangerous
                            thoughts for you to have? (Use these examples)

                            a. Idealizing the high, positive outcome expectancies for use of the
                                drug/alcohol.




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                            b. Overconfidence, desire to test your control by using "just this
                               one time."

                            c. Rationalizations

                                Define: Rationalization is a way of mentally "tricking
                                yourself" into believing something that really isn't true.

                                This can include: Exaggeration (playing up the reward value or
                                positive consequences of the decision).

                                Minimization (playing down the negative consequences).
                                Focusing attention on desired outcomes (usually involving
                                immediate gratification). Neglecting negative outcomes (long-
                                range costs). Presenting "excuses" or phony justifications for
                                using.

                                Rationalizations can be challenged just like any other lies.
                                Question your own rationalizations.


             Discussion Topic: Relapse Factors and Warning Signs
                    Discuss the various emotional, attitudinal, behavioral, and cognitive factors
                    and warning signs that might precede a relapse. Use the board to guide
                    discussion                                                                 --
                    write groups' responses in lists on the board.

             Say In Your Own Words:

             1.     Emotional Factors

                    Can anyone think of any emotions or feelings that might lead to or be
                    warning signs of a relapse? Guide the group as needed; try to include a
                    wide range of responses. Be sure to include the HALT (Hungry, Angry,
                    Lonely, Tired) model. Remind the group that these emotional factors can
                    cue them to use coping strategies to prepare for a high-risk situation.




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             2.      Attitudinal Factors

                     What kind of attitudes could a person have that might lead to or be a
                     warning sign of a relapse? Guide the group as needed; try to include a
                     wide range of responses. Remind the group that these attitudinal factors can
                     cue them to use coping strategies to prepare for a high-risk situation.

             3.      Behavioral Factors

                     What kind of behaviors might lead to or be a warning sign of a relapse?
                     Guide the group as needed; try to include a broad range of responses.
                     Remind the group that these behaviors can cue them to use coping strategies to
                     prepare for a high-risk situation.

                     One coping strategy you can try is to arrange "safe situations" for
                  yourself. In other words, be in places or with people where it would be
                  impossible to use. For example, if your spouse strongly opposes using
                  drugs or alcohol, be with him or her. Can you think of other examples?
                  List these on the board. Help the group with examples if they are having
                  difficulty.

             4.    Cognitive Factors
                   What kind of thoughts might lead to or be a warning sign of a relapse?
                   Again, guide the group through this discussion. If no one mentions
                   RATIONALIZATION, bring it up, help the group to define it. If no one
                   mentions OVERCONFIDENCE, bring it up, help the group to define




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                                         Module 10 Main Points


      There are warning signs and cues that a relapse into drug use or criminal behavior is becoming more
      likely.

      Signs can be negative feelings, bad attitude, risky behaviors and negative thoughts.

      You should have thought of a plan of action before you encounter one of these four factors. That way,
      you will have a solution and support ready to go as soon as needed.

      A few possible coping strategies:
         o Keep repeating to yourself why you need to maintain a total abstinence.
         o Ask treatment personnel to give you feedback when they hear you expressing negative attitudes.
         o Try to arrange "safe situations" for yourself, (situations in which using would be impossible):
            shopping, church, visiting non-using friends.




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                                               MODULE 11
                                             What is Depression?


              Objective: To help participants understand and manage symptoms of Depression.


             Say In Your Own Words:

             Over the next four sessions we will be exploring the idea of emotions or
             feelings. I will be giving you a definition that we will use for each basic feeling
             (FLASH).

             Today we are going to define Sad and discuss Depression:

             SAD= What you feel when you do not get what you want (an unmet expectation/belief) and you
             have given up hope of ever getting it, even though you still want it.

             Everyone feels sad. When we think of unhappy events that have happened in
             the past we feel sad. When we experience loss, we feel sad. On the other hand,
             depression is very intense and long lasting - it significantly interferes with your
             life. Below are the symptoms of Major Depression and how it impinges on
             areas of life:

             Now we are going to explore the primary symptoms of Major Depression.

             •      Depressed mood or diminished interest or pleasure in almost all
                    activities most of the day, nearly every day for at least two (2) weeks
             •      Significant weight loss/decrease in appetite or increase in appetite
                    nearly every day
             •      Insomnia or hypersomnia nearly every day
             •      Psychomotor agitation or retardation nearly every day
             •      Fatigue or loss of energy nearly every day




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             •         Emotions of worthlessness, hopelessness, helplessness or excessive guilt
                       nearly every day
             •         Diminished ability to think or concentrate or indecisiveness nearly
                       every day
             •         Recurrent thoughts of death/suicidal ideation

                         Ask participants to discuss these and ask if any have experienced them.

             What causes depression? There are many explanations available for how a person
             becomes depressed. The reasons one person gets depressed may be different from
             another. What is probably true for all individuals is that many factors contribute to their
             experience of depression and the reasons someone gets depressed may be different at
             different times.

             Depression may be partly ‘handed down’ from parents to children. It is part of their
             physical makeup (‘genetics”).

             Plus...

             It is partly learned (environment - What you learned from your ‘Family of
             Origin’ - What others modeled for you and that you learned from them) and partly a
             result of the way you look at and think about your life - your
             expectations.

             Plus...

             It is partly about external factors - situations that you find yourself in, events that
             happen to you, bad news, a friend’s betrayal etc.

             The question of how the abuse of substances is related to depression has a
             complex answer. Some people think that both issues have a genetic basis and that is
             why many families present both problems. The cause is less important than the notion
             that BOTH problems must be treated at the same time.

             Some think that people take substances in order to feel better (ending up in the long
             run actually feeling much worse with the short term apparently beneficial effects of
             substances leading to the long term costs of deeper depression). It is only natural to
             want to escape the depression and to try to find ways to feel better.


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             The challenge is to find safer more durable alternatives to increase mood
             (prescribed antidepressant, improve quality of self - talk, scrutinize intimate
             relationships, challenge personal expectations, increase awareness of
             irrational thought patterns, attend support groups, cultivate hobbies/interests that
             increase creativity/joy etc.)

                    Instructions to Group Leader:

               •    Pass out Handout: Symptoms of Sadness and Depression

               •    Ask each member to write two situations in the past two weeks in which they
                     felt sad.

               •    Ask them to take 10 minutes to think about each situation in depth and write
                     down the thoughts that seem to stand out about each of the two situations.

               •    Go around the room and ask the members to assess whether in each of their
                     two situations…

             ...Was the feeling in response to a situational loss (sadness)?


             or


             ...Was it depression -- which is situational loss + genetic + learning
             (environment)? It has at it’s core several major symptoms (i.e.: Not being able to feel
             pleasure or enjoy things you used to enjoy, feeling down most days, not having energy
             to do work/fun things, feelings of worthlessness or excessive guilt nearly every day,
             diminished ability to think or concentrate or
             indecisiveness nearly every day, recurrent thoughts of death/suicidal ideation. These
             symptoms last for at least two weeks.)


                    Alternate or additional assignment:

             Ask participants to keep a Diary,     ”Thinking or Feeling Report” of their sad
             feelings and negative thoughts.




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                 Module 11 Handout: Symptoms of Sadness and Depression


             and My Diary / “Thinking or Feeling Report”
             SADNESS = What you feel when you do not get what you want (an unmet
             expectation/belief) and you have given up hope of ever getting it, even though

             you still want it.

                                              VERSUS

             Symptoms of: DEPRESSION =

             • Not being able to feel pleasure or enjoy things you used to enjoy

             • Feeling down most days

             • Not having energy to do work/fun things

             • Feelings of worthlessness, hopelessness, helplessness or excessive guilt nearly every day

             •   Diminished ability to think or concentrate or indecisiveness nearly every day recurrent
                 thoughts of death/suicidal ideation.)

             • Lasts for at least two weeks


                                    My Diary / “Thinking or Feeling Report”
             Date and Time                           Symptoms I felt




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                                         Module 11 Main Points


      Sadness and Depression are two very different things.

      Sadness is a natural and time limited reaction to an unmet need or wish.

      Depression is longer term and has a variety of symptoms. It can be caused by a variety and combination
      of factors: current situation, genetics and environmental learning.


   Sadness- short term, cause and effect can be traced

   Depression- long term (2+ weeks), cause and effect can be from several sources and a combination of
   sources




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                                             MODULE 12
                                    Depression and Substance Abuse


             Objective: To practice with participants to aid in the understanding the relationship of substance
             abuse symptoms of Depression.


             Here is some food for thought:

             • Because you have two disorders (for example: depression (or Bipolar
               Disorder or Schizophrenia) and substance use) the symptoms will interact.
               One disorder can exacerbate (make worse) (example - individuals with
               unipolar depression represent a high-risk group for the occurrence of
               emotions of depression to even moderate amounts of THC) , precipitate
               (cause it) (example - depressed mood occurring and then use of cocaine to
               cope), mask (cover up real source) (example - use of cocaine may cover
               up/be the total explanation for an underlying, (prior to substance abuse)
               depression) or, mimic (imitate) (example - using depressants can cause
               organic mood disorder)

             • The best decisions are made “substance free”.

             • Using your “NOT” substance of choice as a substitute will probably
               remind you of the times you used your favorite/most addicting substance. This
               could set off powerful urges and cravings & using other drugs will likely set you
               up to become addicted to other substances. (I’ll just drink some wine to get to
               sleep—that’s ok because it isn’t marijuana)

             • Negative moods can be changed in other ways than through the use of
               substances.




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                    Instructor WARNING: Prep yourself for comments about your prescription
                    antidepressant medications being “Just another kind of dependence”. Have a ‘pat’
                    answer ready (For example: People with Diabetes take Insulin, Individuals with heart
                    disease take cardiac medication etc.).

                    Discussion Questions:

             Now let’s discuss what happens when you use substances to cope with
             depression and sadness (d/s).

             •      How many of you have found a substance that decreases your d/s?
             •      If yes, does this last for the long run?
             •      How many of you have found a substance that increases your d/s?
             •      What are the problems (needing more to get same effect (tolerance),
                    having to get prescriptions or get it on the street , expensive, leads to cloudy
                    thinking, etc.)
             •      Have you noticed that you have gotten short term reduction but that the
                    way you think (your “cognitions”) and situations remain the same?


                    Exercise:

             Go around the group and ask each participant about the experience of depression
             while incarcerated and how they have coped with it.




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                                          Module 12 Main Points


      Sometimes people will use street drugs to try to “treat” their Depression. There are several problems with
      this plan:
          o Only a short term fix
          o Can make the Depression even worse.
          o Can “hide” other symptoms and problems.
          o It’s illegal and results in jail and prison.
          o Need more and more to get the same results (tolerance).




      Sometimes people will convince themselves that it is okay to use other street drugs (as long as it is not
      their original drug of choice) to deal with their depression. Again, there are problems with this plan:
         o All the problems listed above.
         o Often the “substitute” drug just makes the user crave their drug of choice all the more.

      Psychotherapy is also an effective treatment, especially when in combination with medication.




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                                               MODULE 13
                                              Fear and Anxiety



              Objective: To help participants understand & manage symptoms of Anxiety.


             Say In Your Own Words:

             Today we are going to talk about Fear and Anxiety. First let’s define Fear.

                    Write definition on the board

              FEAR = What you feel when you believe you know something is going to happen to
             you (a future expectation /belief) and it is not going to be pleasant.

                    How are Fear and Anxiety different? (Ask the group for ideas)

             Everyone feels fear. Fear helps us to be careful; it can keep us out of danger. When
             we think of an event where something negative may happen, we feel
             fear (You have an appointment with the dentist because of tooth pain. You
             worry that the tooth may need to be pulled. You are concerned it will be
             painful or take a long time to heal. etc.). When we think we may experience
             loss we feel fear.

             Anxiety is fear that is out of control and doesn’t serve a helpful purpose. It may
             feel “free floating”--and not connected to any specific event or thought. It gets in the
             way and prevents us from handling things the way we would like to.

             Situations are appraised as dangerous or threatening when OBJECTIVELY
             they are not. The person avoids or escapes to the detriment of other goals.

             Now let’s talk about the different kinds of anxiety and their symptoms.




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                    Below are some of the different kinds of severe anxiety and the symptoms that
                    go along with each one2. Go over each one with the group.


             Overview

             Everyone experiences feelings of anxiety or stress and worry from time to time.
             Anxiety is a normal part of life and only becomes a problem when it reaches levels that
             interfere with people’s daily lives. Chronic anxiety can have harmful effects on the
             body, on emotional health, and on the ability to think clearly. In essence, it is
             maladaptive and should be treated. According to prominent authorities in the field
             (Zinbarg, Craske, & Barlow, 1993):

                    Anxiety can be HELPFUL when it

                            Helps motivate people to prepare for important events (e.g., studying for
                            tests or planning ahead for a big event) or to deal with their
                            problems

                            Helps prepare the body to deal with difficult or dangerous situations by
                            increasing heart rate and breathing and gearing up for what is known as the
                            “fight or flight response”


                    Anxiety can be HARMFUL when it


                            Occurs over long periods of time

                            Occurs over long periods of time in situations where it is unhelpful (i.e.,
                            when a person doesn’t have control over the stressful situation, worrying
                            about it only puts unnecessary strain on the body).




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             2
                 Diagnostic and Statistical Manual of Mental Disorders (DSM IV,1994,p.393)




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             Anxiety problems generally are caused by a combination of biological and
             environmental risk factors. Some people, as a result of their personality
             traits, may be more prone to worry or be fearful in situations where other
             people would not. They may also inherit from their parents a biological
             vulnerability to the effects of worry on their bodies. Combined with a
             stressful lifestyle or anxiety-provoking events that happen to occur to them
             over the course of their lives, these biological vulnerabilities may increase the
             likelihood that a particular person will experience anxiety-related problems.

             Substance use can also be a risk factor affecting the level of anxiety people
             experience. Some drugs such as cocaine might serve to worsen anxiety,
             causing it to reach harmful levels. Other drugs such as marijuana might
             reduce it to the point where it is no longer a positive motivating factor in
             someone’s life (e.g., a marijuana user may lose the motivation to look for a job that
             worrying about being unemployed might provide).

             On the other hand, someone might turn to drugs (e.g., alcohol) to reduce
             harmful levels of anxiety instead of seeking help. Before long the person may develop
             an addiction to the drug and still experience problems with anxiety. In this case, anxiety
             would be a risk factor for developing an addiction to
             drugs or alcohol.

             There are a number of very effective treatments for anxiety disorders ranging from
             medications to psychotherapy. There are also a number of different
             anxiety-related disorders people may have. Some of them include social
             anxiety disorder (social phobia), panic disorder, and posttraumatic stress
             disorder. In the following three sections, these disorders will be described as they are
             defined in the American Psychiatric Association’s Diagnostic and
             statistical manual of mental disorders, fourth edition (1994). Afterward, their
             connection with substance use will be discussed.

             Social Anxiety Disorder
             Social Anxiety Disorder, also known as social phobia, is a condition in which people
             experience excessive or unreasonable amounts of fear in social or
             performance situations in which embarrassment may occur. While being in these
             types of situations is anxiety-provoking for most people, it is so anxiety provoking for
             people with the disorder that they may avoid such situations, even when doing so
             interferes with their normal lives.

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             People with social phobia may even become anxious at just the thought of
             being in a potentially embarrassing social situation. Some examples of
             situations where people with social anxiety disorder may become overly
             anxious can include public speaking, eating in front of others, using a public restroom,
             attending parties, and speaking to authority figures. Examples of
             situations that would not be considered social phobia are ones where the
             amount of anxiety is appropriate for the situation and does not interfere with one’s daily
             life (e.g., worrying about your safety in a dangerous
             neighborhood). A good rule of thumb is to consider whether most other people would be
             similarly anxious in the same situation.

             It has been estimated that social phobia will occur over the course of a
             person’s lifetime in 3% to 13% of the population, with women being slightly
             more at risk of experiencing it than men. Social phobia tends to run in
             families (biological risk factor) and typically begins in the mid-teens. It can,
             however, start in early childhood. Onset may abruptly follow a stressful or
             humiliating situation (environmental risk factor) or just seem to happen over
             time for no apparent reason. Duration is frequently continuous over the
             lifespan.

             People may sometimes use drugs or alcohol in order to help “take the edge
             off” of the anxiety-provoking situations. For example, someone might have a few
             drinks before trying to meet new people or smoke marijuana before
             talking to the boss. Alternatively someone could engage in an embarrassing behavior
             while under the influence of drugs or alcohol and develop a fear of similar future
             embarrassment.


                       Question 1: Give an example of a social situation in which most
                       people would experience anxiety. Give an example of a social
                       situation where most people would not experience anxiety and where
                       it might be
                       considered excessive if someone did experience it.

                       Question 2: How do you think substance abuse would affect this
                       disorder? What would be a more effective way of dealing with such
                       anxiety?

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                       Question 3: Discuss some of the biological and environmental risk
                   factors potentially leading to and being caused by social anxiety disorder.



             People experiencing social anxiety disorder, or just anxiety in general, may also
             experience what is known as a panic attack. Panic attacks will be described in the
             next section.


             Panic Attacks
             Panic attacks are periods of intense fear or discomfort that occur in the absence of
             real danger. They are accompanied by a number of the following physical
             symptoms and thoughts:

                    • Palpitations, pounding heart, or accelerated heart rate
                    • Sweating
                    • Trembling or shaking
                    • Sensations of shortness of breath or smothering
                    • A feeling of choking
                    • Chest pain or discomfort
                    • Nausea or abdominal distress
                    • Feeling dizzy, unsteady, lightheaded, or faint
                    • Feelings of unreality or being detached from oneself
                    • Fear of losing control or going crazy
                    • Fear of dying
                    • Numbing or tingling sensations
                    • Chills or hot flushes

             A panic attack is most often provoked by some situation the individual finds
             distressing (environmental risk factor). It has a sudden onset and builds to a peak
             rapidly, usually in 10 minutes or less. It often is accompanied by a sense of
             looming danger or doom and an urge to escape. People having one of these attacks
             will describe the fear as having been intense and report thinking they were about to
             die, lose control, have a heart attack or stroke, or “go crazy”. They also usually
             report having had an urgent desire to flee from wherever the attack was occurring.




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                    Panic attacks can be:

                    • Unexpected (i.e., the attack seems to occur spontaneously without any
                    triggering event or thought)

                    • Always occur in a particular situation (e.g., every time one sees a
                       snake)

                    • Sometimes occur in a particular situation (e.g., be more likely to occur while
                    driving but not occur every time one drives and sometimes
                    occurring when not driving)

             Certain drugs can help cause a panic attack. One common example is when people
             unintentionally eat or drink too much caffeine. The caffeine makes their hearts
             race and their bodies tremble. Experiencing these symptoms without realizing
             what is causing them can be very scary and create a building cycle of anxiety that
             leads to a full-blown panic attack. People might also mistakenly cause a similar
             situation to happen by mixing different drugs or combining drugs with medications
             without knowing how these drugs or medications will interact. For this reason,
             when people are speaking to a doctor about taking medication, it is very important
             to be honest about any drugs or medications they are using or plan to use while on
             the medication.

             Sometimes people who have had a panic attack begin to worry about the possibility
             of having a future panic attack and use drugs or alcohol in an attempt to prevent
             the attacks. Again, the most obvious example would be drugs that relax people or
             “mellow them out” such as marijuana. However, people could also choose to
             “drown their worries” with alcohol or escape from reality with LSD or heroin.




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                        Question 4: What are some biological and environmental risk
                        factors causing or caused by panic attacks?

                        Question 5: If you ever experience a panic attack, what would be a
                        good way to handle the situation? (A: Take deep, slow breaths and
                        calm yourself down. Tell yourself that there is no real danger and
                        that you are safe. Afterward, try to identify any situations or thoughts
                        that may have caused the attack. ***Note: If you have any doubt that
                        you may be having a heart attack or stroke, it is important that you
                        get to a hospital as soon as possible. If it turns out that you were
                        experiencing a panic attack after all, you might still benefit from
                        trying to identify causal situations or thoughts. Once identified, you
                        can look for them if you ever experience these symptoms again.)




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                                           Module 13 Main Points


      Fear and Anxiety are two very different things.

      Fear is a natural and time limited reaction to an event.

   Event                Fear

      Anxiety problems generally are caused by a combination of biological and
      environmental risk factors.

      In many cases, there is no real concrete reason for the anxiety.

   Event/Biology/?               Anxiety

      Limited anxiety can be motivating- You are anxious about how you will do on a test, so you put in a
      few extra hours of studying.

      Unlimited anxiety can interfere with daily life- You are so anxious about how you will do on a test that
      you don’t eat, sleep or go to work for three days and instead spend every moment studying.

      Two common types of Anxiety Disorders
        o Social Anxiety
        o Panic Attacks


       There are legal drugs that can be prescribed for these disorders and they are more effective and
       predictable than street drugs.




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                                             MODULE 14
                               Understanding Posttraumatic Stress Disorder



             Objective: To help participants understand & manage symptoms of anxiety and posttraumatic
             stress disorder.


             Here Module 14 expands Module 13 by introducing PTSD as another common
             form of anxiety disorder.

             Posttraumatic Stress Disorder (PTSD)
             Posttraumatic Stress Disorder (PTSD) may occur when a person has been exposed
             to a traumatic event such as a physical assault, rape, or witnessing a robbery
             (environmental risk factor). This event can involve actual or threatened death or
             serious injury, or it can take the form of a threat to the physical well being of
             oneself or others. People with PTSD often repeatedly re-experience the trauma by
             remembering the event, having dreams about it, acting or feeling as if the trauma
             were reoccurring, or by experiencing intense psychological or physical distress at
             exposure to reminders of it. (While it is common for people to remember a past
             trauma, people with PTSD often become very distressed when they do.)

             People with PTSD often try to avoid reminders of the trauma or situations
             associated with the trauma such as doing things to avoid thinking about it or
             avoiding places that remind them of it. They may also experience feelings of
             detachment from others, an inability to recall the event, or have a sense of doom
             about the future. Other symptoms include the following:

                    •   Difficulty falling asleep or staying asleep
                    •   Difficulty concentrating
                    •   Irritability or outbursts of anger
                    •   Always feeling on alert
                    •   An exaggerated startle response




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             PTSD can occur at any age and to anyone who experiences a severe trauma.
             Severity and duration of the trauma are the most important factors affecting the
             development of the disorder.

             People who experience such traumatic events sometimes turn to drugs or alcohol to
             help them cope. They may take drugs that relax them such as sedatives or alcohol, or
             they make take other drugs with the intention of escaping from reality and their fears
             for a while.

             Drugs and alcohol can also put someone at risk for being involved in traumatic
             experiences. For example, someone could get raped while drunk or under the
             influence of drugs or could be involved in a driving accident while under the
             influence.

                    Question 1: How might substance use enhance or make some of
                    these symptoms worse? How else could you deal with these
                    symptoms?
                    Question 2: What are the biological and environmental risk
                    factors causing or caused by PTSD?


             Read the following:

             Case Story 1
             James came from a lower middle class family, the younger of two children. From his
             childhood his chief memories were of his mother and father getting into violent
             fights, cursing at each other and breaking things and of his father coming home high
             on drugs and getting arrested and sent to prison for drug related and assault charges.

             After his father went to prison, James’s family could not support themselves
             and life got even harder to bear. James was very embarrassed about his
             father but also angry with him for letting down the family. At school, he had
             a hard time sitting still during class. He found it difficult to concentrate on
             the work and pay attention. All he wanted to do was talk to girls, crack jokes,
             or draw - anything but study and learn. He sought everyone’s approval by
             trying to be the funniest, loudest, craziest person wherever he was. He even
             tried to be the one to drink the most, use the most drugs, steal the most, and
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             fight the most.




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             James became obsessed with obtaining the approval of his peers - to the point where
             he would lie awake at night worrying about fitting in with the crowd
             and trying to think of new ways to impress people. Dealing seemed to be the best
             way to fit in.

             James started trying to work his way in with the dealers. They had the most
             money, they got all the pretty women, and they seemed to be the most
             respected and feared. He had to start at the bottom of the ladder, but James
             soon began to climb his way to the top. He also found himself constantly on
             edge, worrying about getting caught and sent to prison and becoming a failure
             and embarrassment like his father. One night James woke up in the middle of
             the night shaking and sweating. His heart was racing, and he couldn’t catch
             his breath. His chest hurt too. He was afraid that he was having a heart
             attack.

                            Question 3: What symptoms of anxiety is James experiencing?
                            Question 4: How did his life as a drug user and dealer affect
                            his mental health?

                            Question 5: What decisions lie ahead for James?



             Connection Between Anxiety Disorder and Substance Abuse
             Substance abuse occurs in many patients with anxiety disorders. They begin taking
             the drugs or alcohol to lessen the symptoms they are having and to help them
             “cope” with their problems. Some of these substances can actually lessen the
             symptoms of anxiety, but they can also carry negative consequences as well. Many
             impair judgment or coordination, run the risk of addiction, and may lead to legal
             consequences. Drugs and alcohol do not treat the anxiety problems directly, but
             instead they cover up the symptoms so the user doesn’t always notice they are
             there. Taking them is like trying to put out a match with a fire hose. You might hit
             the match, but you hit a lot of other unintended things as well - possibly with
             negative consequences.

             Anti-anxiety medications are specially intended for reducing the specific

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             symptoms of anxiety disorders and have fewer potentially negative effects on the




             body than drugs and alcohol. In addition, a number of types of psychotherapy have
             been shown to be quite effective in treating anxiety disorders.

                       Question 6: What are some specific negative effects that drugs
                       alcohol could have on someone who was trying to use them to
                       combat an anxiety disorder?

                       Question 7: Have you or someone you know tried to use
                       substances to treat anxiety? What happened?



             Treatment
             Everyone experiences anxiety. Having some anxiety is a good thing. It motivates
             people to prepare for upcoming events, and it helps them deal with crises when
             they arise. Anxiety becomes a bad thing when it is so strong or happens so often
             that it interferes with people’s daily lives. When this happens, the anxiety takes its
             toll on physical, emotional, and mental health. It becomes a disorder at this point.

             Many people have anxiety disorders. However, there are very good treatments for
             anxiety problems. The first step is to speak with a doctor or with a mental health
             professional. Receiving help in the form of physician-prescribed medications or
             psychotherapy would be ways to increase one’s protective factors for anxiety-
             related problems.
             Psychotherapy
             Psychotherapy has also been shown to be quite effective in treating anxiety
             disorders. People often obtain treatment for these disorders in individual or group
             therapy. Therapy takes time (often several months) and hard work on the part of the
             client, but, unlike medications that only work while people are taking them, the gains
             from therapy are often long term, lasting well after therapy is complete.
             Sometimes, people will treat anxiety disorders by taking anti-anxiety medications in
             conjunction with psychotherapy.


             Medication
             Anti-anxiety medications are quite effective in reducing the symptoms of anxiety
             and often have minimal side effects. They can be obtained by prescription from a
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             doctor who should monitors the patient’s care while they are in use. Sometimes
             people with anxiety problems will take anti-anxiety medication once in a while to




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             help them get past periods of intense stress in their lives. Sometimes they will take
             them for longer periods of time.

             One common category of anti-anxiety medication is the benzodiazepines. Due to
             side effects of using them, it can be dangerous for people taking benzodiazepines
             to drive or operate some machinery, especially when first beginning the
             medication. When combined with other medications or drugs, benzodiazepines
             can present a problem by interacting with them to create undesired and dangerous
             effects. This interactive effect is most notable when benzodiazepines are taken
             together with commonly used substances such as alcohol. The interaction of
             benzodiazepines with alcohol can lead to serious and possibly life-threatening
             complications. Following a physician’s instructions is important, as is being honest
             about any other drugs or medications (even over-the-counter ones) one is taking or
             plans to be taking. When combined with alcohol, anesthetics, antihistamines,
             sedatives, muscle relaxants, and some prescription pain medications,
             Benzodiazepines depress the central nervous system even more than they do alone.
             Particular benzodiazepines may influence the action of some anticonvulsant and
             cardiac medications as well. They have also been associated with abnormalities in
             babies born to mothers who were taking these medications during pregnancy.

             In addition to their interactive properties with other drugs and alcohol, there is the
             potential for people using benzodiazepines to become addicted to them. Because of
             this potential for addiction to them, it is very unusual for addicts to be
             prescribed benzodiazepines.

             With benzodiazepines there is a potential for development of tolerance and
             dependence in addition to the possibility of abuse and withdrawal reactions. As
             such, the medications are generally prescribed for brief periods of time - days or
             weeks and sometimes intermittently, for stressful situations or anxiety attacks. It is
             important to consult with a physician before discontinuing a benzodiazepine
             because a withdrawal reaction can occur if the treatment is abruptly stopped.
             Withdrawal symptoms can include anxiety, shakiness, headache, dizziness,
             sleeplessness, loss of appetite, and, in more severe cases, fever, seizures, and
             psychosis. A withdrawal reaction may be mistaken for a return of the anxiety
             because many of the symptoms are similar. Thus, after benzodiazepines are taken for an
             extended period, the dosage is gradually tapered off before being completely stopped.
             The following table lists some common anti-anxiety medications, their
             average dosage ranges, and their possible side effects.




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                                              Anti-Anxiety Medications


                Type of Drug    Brand        Generic               Average              Possible Side
                                Name         Name                  Dosage               Effects
                                                                   Range
                                                                   (mg/day)
                Benzodiazepines Ativan      Lorazepam                 2-10    Drowsiness, loss of
                                 Compazine Prochlorperazine         15-150    coordination, fatigue, mental
                                 Klonopin   Clonazepam               0.5-16   slowing, and confusion
                                 Librium    Chlordiazepoxide         5-100
                                 Valium     Diazepam                  2-40  All benzodiazepines have
                                 Xanax      Alprazolam               0.75-4 the potential for addiction
                Non              Buspar     Buspirone                15-60  Dizziness, nausea, headache,
                Benzodiazepine                                              fatigue, nervousness, light-
                                                                            headedness, and excitement
                                *Atarax      Hydroxyzine           200-400 Sleepiness, dizziness, and
                                (Vistaril)   hydrochloride                  dry mouth



             Alternative Treatments
             Exercise, both aerobic and strength training, has been scientifically shown to help
             reduce the symptoms of anxiety disorders. Yoga, meditation, and engaging
             relaxing hobbies may also be helpful for some people.


             Summary

                 • It is normal for everyone to experience anxiety and worry.

                 • In moderate amounts anxiety can be helpful. It is only maladaptive and
                     harmful when it occurs over long periods of time and in situations where
                     there is no benefit to worrying (i.e., when one has no control over a
                     situation).

                 • People can have biological risk factors for anxiety such as personality traits
                    that cause them to worry easily about things and biological vulnerability to
                    the physical effects of that worry.




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                 • Environmental risk factors for anxiety would include a stressful lifestyle and
                    unexpected events that occur for some people over the course of their lives
                    (e.g., being the victim of a violent crime).

                 • Anxiety problems can also be caused or worsened by substance use. In this
                    case substance use would be a risk factor for anxiety problems.

                 • Sometimes people deal with anxiety problems by self-medicating with drugs
                    or alcohol. In this case anxiety problems would be a risk factor leading to
                    substance use.

                 • More effective ways of dealing with anxiety problems (protective factors)
                    include medications prescribed and monitored by physicians and individual
                    or group psychotherapy.


                     Ask participants to share experiences. If reluctant to share personal
                  experiences ask them to talk about the fear or anxiety they’ve seen in others.




             References
                    American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
             disorders (4th ed.). Washington, DC: Author.

             Zinbarg, R.E., Craske, M. G., & Barlow, D. H. (1993). Mastery of your anxiety and worry
             (MAW) program. Albany, New York: Graywind Publications, Inc.




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                                         Module 14 Main Points


      Another common Anxiety Disorder is Posttraumatic Stress Disorder (PTSD).
      Memories of a past traumatic event cause severe stress and inability to function.
      Sometimes people will use street drugs to try to “treat” their Anxiety. There are several problems with
      this plan:
          o Only a short term fix
          o Can make the Anxiety even worse.
          o Can “hide” other symptoms and problems.
          o It’s illegal and results in jail and prison.
          o Need more and more to get the same results (tolerance).

      Psychotherapy is also an effective treatment, especially when in combination with medication.




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                                               MODULE 15
                                        What is Bipolar Disorder?

             Module 19
                                      t are Bipolar Disorders?

                    Instructions to Group Leader:

             Remember to make this group interesting to the group members by
             welcoming their input and discussion and using the exercises and discussion
             questions. Present the material in an interactive format. Don’t just read the material but
             say it in your own words in a way that you know the participants will understand.

             You can break this module up into more than one group or skip some
             exercises if you cannot fit it all into one group. Another idea would be to have
             participants complete some of the exercises as homework or with their
             counselors. You can also skip or modify exercises if they are not appropriate for your
             program or treatment population.


             Overview
             Everyone has ups and downs in mood; happiness, sadness, and anger are normal
             emotions and are a normal part of everyday life. In contrast, bipolar disorder is a
             medical condition in which people have mood swings out of proportion to things
             going on in their lives. These mood swings affect thoughts, feelings, physical
             health, behavior, and functioning. Bipolar disorder is not the person’s fault, nor is
             it the result of a “weak” or unstable personality. It is a treatable medical disorder
             for which there are specific medications and other therapies that help most people.

             Bipolar disorder is the medical name for manic depression. According to the
             American Psychiatric Association’s Diagnostic and statistical manual of mental
             disorders, fourth edition (1994), a person with this disorder sometimes has:

                    • an extremely elevated mood (mania) which may range from mild mania
                       (hypomania) to more severe mania




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                    • an extremely low mood (depression) which can be very brief to long-
                      lasting

                 In between the mania or depression, the person's mood may be normal.
             Sometimes a person with bipolar disorder may have additional psychotic features such
             as delusions or hallucinations. The symptoms of bipolar disorder can cause
             considerable disturbance in a person's life. The experience can be described as a roller
             coaster ride that doesn’t stop. A person with bipolar disorder doesn’t
             generally have an episode of depression, then an episode of mania, in equal
             amounts. The cycles are often unpredictable and of varying lengths.

             Many people with bipolar disorders can function normally. Many famous people such
             as Robert Downey Jr., Jean-Claude Van Damme, Patty Duke, Edgar Allen Poe, and
             Brian Wilson have had bipolar disorder and still have made significant contributions
             to society.


                    Question 1: What might be some symptoms of bipolar disorder?

                     Question 2: What do you think would happen if someone used drugs or alcohol
                 to cope with depression and mania?


             Symptoms of Bipolar Disorder (taken from the DSM-IV, 1994)
             At least some of the symptoms for bipolar disorder interfere with the person's day to-day
             functioning. The symptoms can be grouped as manic symptoms, depressive symptoms,
             and other symptoms.


             Manic Symptoms
              (Not all of these symptoms must be present for a person to have had a manic
              episode.)

                    • Euphoric Mood - Mood is elevated, such as feeling incredibly excited

                    • Irritability - Easily angered or irritable, especially when others seem to
                       interfere with the person's plans or goals


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                    • Inflated Self-Esteem - Extremely self-confident to the point of being
                       unrealistic about abilities (grandiosity)

                    • Decreased Need for Sleep - Only a few hours of sleep may be needed each
                       night (such as less than four hours) for the person to feel rested

                    • Talkativeness - Talks excessively and may be difficult to interrupt

                    • Racing Thoughts - Thoughts come so rapidly that the person finds it
                       difficult to keep up with them or express them

                    • Distractibility - Attention is easily drawn to other things and can interfere
                       with talking with other people, enjoying an activity, or ability to work

                    • Increased Goal-Directed Activity - A great deal of time is spent pursuing
                       specific goals, at work, school, or in sexual activity

                    • Excessive Involvement in Pleasurable Activities - Common problem areas
                       include sexual indiscretions, spending sprees, increased substance
                       abuse, or making foolish business investments


             Depressive Symptoms
             Depressive symptoms reflect the opposite of manic symptoms, with a low mood
             and inactivity as the major features. Not all symptoms must be present for a person to
             have had a depressive episode.

                    • Depressed Mood - Most of the day, nearly every day

                    • Diminished Interest or Pleasure - In all, or almost all, activities most of
                       the day, nearly every day

                    • Change in Appetite and/or Weight - Significant weight loss when not
                       dieting, or a weight gain; decrease or increase in appetite nearly every
                       day


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                    • Change in Sleep Pattern - Inability to sleep or sleeping too much nearly
                       every day

                    • Change in Activity Level - Observable by other people, not just feelings
                       of restlessness or being slowed down

                    • Fatigue and Loss of Energy - Nearly every day

                    • Feelings of Worthlessness, Hopelessness or Helplessness - Nearly
                       every day

                    • Inappropriate Guilt - Not just self-reproach or guilt about being sick

                    • Recurrent Thoughts about Death - Not just fear of dying, but recurring
                       thoughts of suicide without a specific plan, a suicide attempt, or a
                       specific plan to commit suicide

                    • Decreased Concentration or Ability to Make Decisions - Nearly every
                       day

             Other Symptoms
             People with bipolar disorder may have other psychiatric symptoms at the same
             time they experience manic or depressive symptoms. However, not all people
             experience these symptoms, and they are not needed to make a diagnosis of bipolar
             disorder. Some of the more common of these other symptoms include:

                    • Hallucinations -- False perceptions such as hearing voices

                    • Delusions -- False beliefs, such as paranoid thinking




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                        Question 3: People often feel great while they are manic (e.g., euphoric mood,
                    inflated self-esteem). If this is the case, why would they, or should
                    they, try to get those symptoms treated?

                 Answer: They may feel good but are at risk of engaging in behaviors that
                 are harmful to themselves or others.

                        Question 4: What are some environmental risk factors that
                        might increase the chances someone with a biological
                        predisposition for bipolar disorder would
                        develop it?

                 Answer: Stress, drug use, poor diet and sleeping habits.

                        Question 5: Do you know anyone who has experienced these symptoms?




             Connection Between Bipolar Disorder and Substance Abuse


             Substance abuse occurs in many patients with bipolar disorder. Alcohol and other
             drug abuse are not only common among bipolar patients but also may contribute
             significantly to treatment resistance and poor treatment outcome. Separating the


             Understanding the symptoms of bipolar disorder and substance abuse can be
             difficult because acute intoxications and withdrawal can mimic the illness. How do
             we know if the symptoms are due to substance use or bipolar disorder?
             Typically, if manic or depressive symptoms persist or worsen after alcohol or drug
             detoxification, treatment for a mood disorder may be needed.

             Some drugs including marijuana, downers, alcohol, and opiates seem to dull the
             effects of mood swings temporarily, only to cause other symptoms later. Other
             drugs such as speed and cocaine can enhance manic depression and send people
             into manic states, often followed by deep depression and psychotic symptoms. The
             continued use of drugs by people with bipolar disorder possibly stems from their
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             discovery of short-term release from the symptoms of mania or depression. The
             unfortunate reality is that the relief of symptoms by using drugs or alcohol is short-
             lived and often begins a cycle of substance abuse. An individual struggling with both
             bipolar disorder and substance abuse offers this:

                    “Self-medicating treats the symptoms, not the underlying illness. The more
                    we use a substance other than supervised medication, the worse our
                    symptoms become, and we often find ourselves in a hole which is very
                    difficult to climb out of.”

             There are many challenges to treatment for those individuals who are struggling
             with co-occurring disorders. However, if the client takes control and works with a
             counselor through various treatments, it is possible to find a treatment that fits the
             client’s needs.




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             Module 15 Handout: Case Studies
             Read the following:
             Case Story 2
             Leo was a young man full of life and potential, but he could never seem to get over that
             final hurdle in life that would, in his words, “make me a success.” Though he was
             married with two kids and appeared to be happy in his middle-class suburban
             neighborhood, Leo could never maintain a steady work history. Luckily he had
             inherited some money and his home from a deceased relative, and his wife worked for a
             medical clinic. If the family had depended solely on Leo providing for them, they
             would have been in trouble.

             One day while meeting his wife at the clinic for lunch, Leo struck up a
             conversation with a psychiatrist who worked at the clinic. As usual, Leo was
             between jobs and began discussing with the psychiatrist how much he hated his
             previous employer and that in all his years he had yet to find a job that made him
             happy. He also discussed his history of mood swings that left him depressed and
             withdrawn from his family and work. During these periods, his alcohol
             consumption would increase drastically, and his experimentation with
             hallucinogens got worse, putting a strain on his marriage and usually resulting in
             another job change. Leo had “tried” over the years to get a grip on his mood
             swings. Every time he assumed he had things under control, his mood swings
             would flare up again, his use of alcohol and hallucinogens would increase, and he
             would change jobs again.

             The psychiatrist asked Leo to make an appointment and suggested he bring his
             wife. At the first appointment, the psychiatrist suggested that Leo try some mental
             and relaxation exercises. Leo was later diagnosed with bipolar disorder and given
             medication.

             Two years later, Leo’s mood swings have subsided, and he no longer uses alcohol and
             hallucinogens. He started his own business, which is thriving, and his life is finally
             looking like he had envisioned when he graduated college.


                Question 5: Why do you think Leo began using alcohol and drugs?




                Question 6: What effect did these substances likely have on Leo’s mood swings?

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                Module 15 Handout: Case Studies
               Read the following:
              Case Story 3
              Lisa had a wonderful life. She had so much going for her. She had three great
              children and was married to a special man. There was so much to do and so much to
              live for - and so little time! One day after watching a television show about
              architects Lisa decided she had found her calling. She would be a cashier by day and an
              architect by night. She began to create designs of houses and office
              buildings, often working late into the night. That was no problem, however,
              because she was so excited about her new calling that she often found she couldn’t sleep
              until quite late anyway.

              Lisa had so many good ideas for building designs that she found it hard to finish
              one design before moving on to the next idea. One evening, while working on a
              new design, Lisa came to the realization that she could also decorate the insides of the
              buildings as well as design the outsides. She should become an architect and
              interior decorator!

              Soon, Lisa’s husband began to turn into a real pessimist, saying things like she
              couldn’t be an architect without being trained or at the very least finishing her high
              school degree. That didn’t stop Lisa; she knew that she had natural ability and that was
              all she needed.
              After a couple more weeks, Lisa found that she could no longer keep up with the
              hectic pace she had set for herself. In fact, she began sleeping more and more,
              sometimes as much as half the day. She also began to feel down on herself,
              thinking that her husband was right - she couldn’t be an architect. What a stupid
              idea. She began to feel guilty for wasting her time and for neglecting her family.
              She began to feel that she was a horrible mother and person and didn’t deserve
              such a wonderful family. Maybe she should just put an end to all the foolishness
              once and for all.
                    Question 7: Identify Lisa’s symptoms of bipolar disorder.



                    Question 8: What drugs might she turn to in order to combat her depressive
                    symptoms?


                     Question 9: What would be the likely result of using these drugs in the short
                     term?
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                   Question 10: What would be the likely result of using these drugs in the long
                   term?




             Treatment
             Clients who have been diagnosed with bipolar disorder may feel they are the only
             people facing the difficulties of this illness. But in the U.S. alone, more than 2.2
             million people have bipolar disorder. There is no cure for bipolar disorder, but,
             fortunately, very effective treatments are available to stabilize moods and help
             clients regain and maintain a satisfying and productive life. Some of the most
             common treatments for bipolar include medication, psychotherapy, and support
             groups.


             Medication
             Generally, if the symptoms of bipolar disorder last for 14 days after detoxification,
             medication can be beneficial. The most common medications used to control the
             symptoms of bipolar disorder are mood stabilizers, antidepressants, and
             anticonvulsants. Occasionally, antipsychotics are used (e.g., zyprexa being used as
             a mood stabilizer). A doctor also may prescribe other medications to help with
             insomnia, anxiety, restlessness, or psychotic symptoms. It is important that medication
             be taken as prescribed, usually every day, on a regular basis. A person may need to
             take medication over the course of his/her lifetime. However, these drugs are not
             addictive, and people do not develop tolerance to them and require higher doses.

             Successful management of bipolar disorder requires a great deal from the client.
             There will almost certainly be many times when a client will be sorely tempted to stop
             medication because: (1) “I feel fine,” (2) “I miss the highs,” or (3) “I am
             bothered by side effects.” Clients who stop medication probably won’t have an
             acute episode immediately in the next day or weeks but will probably have a
             relapse eventually.

             Mood stabilizers - Lithium is the most common of these drugs. Specific
             symptoms may be treated with other medications such as antipsychotics and
             antidepressants. Many people experience few or no side effects from lithium. Some side
             effects are temporary and go away after a period of several weeks or months. Examples
             of common side effects include: nausea, stomach cramps, thirst, fatigue, headache, and
             mild tremor.



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             Anticonvulsants - (medications originally developed for the treatment of seizure
             disorders) These medications tend to act more rapidly on acute mood disturbances,
             especially mania. Like lithium, these drugs have some side effects, and certain
             precautions must be exercised when taking them. Often these side effects are
             temporary, but sometimes they may continue for longer periods of time. Some of the
             most common side effects include fatigue, muscle aching or weakness, dry
             mouth, constipation or diarrhea, loss of appetite, nausea, skin rash, headache,
             dizziness, decreased sexual interest, and temporary hair loss.

             Antidepressants - Although mood stabilizers by themselves can sometimes pull
             clients out of a depression, they also may need to take a specific antidepressant to treat
             the depressive episode. However, if given alone, antidepressants can
             sometimes cause a major problem in bipolar disorder by pushing the mood up too high.
             Therefore, antidepressants are sometimes given together with a mood
             stabilizer to prevent this from happening. Antidepressants usually take several
             weeks to begin showing full effect, so clients shouldn’t get discouraged if they
             don’t feel better right away.




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             Precautions When Taking Medications
             Some of these drugs may cause sedation, and therefore appropriate precautions
             must be taken when driving or operating heavy machinery. When a person is
             taking an anticonvulsant, the use of alcohol is often not advised because the effects of
             alcohol are greatly increased. The effects of sedative drugs are also enhanced by
             anticonvulsants. People are usually not prescribed more than one type of
             anticonvulsant medication at a time.



                                                 Mood Stabilizing Medications


              Type of Drug      Brand        Chemical Name         Average    Possible Side Effects
                                Name                               Dosage
                                                                   Range
                                                                   (mg/day)
              Lithium           Eskalith     lithium carbonate     900-3600   Tremors, dry mouth,
                                Eskalith                                      muscle weakness, fluid
                                Controlled                                    buildup, diarrhea, nausea,
                                Release                                       vomiting, mental
                                                                              confusion, lack of
                                                                              coordination, drowsiness

              Anticonvulsants   Tegretol     carbamazepine         100-2000   Nausea, vomiting,
                                Depakene,    valproic acid         125-2000   indigestion, tremors,
                                Depakote                                      drowsiness, weight gain,
                                                                              elevated liver enzymes
                                Lamictal     lamotrigine           25-500     Skin rashes, sensitivity to
                                                                              the sun, headaches,
                                                                              dizziness, nausea,
                                                                              weakness, tiredness,
                                                                              blurred or double vision



             Psychotherapy
             Psychotherapy can play an important role in reducing the stresses that can trigger
             manic and depressive episodes. Sometimes being in therapy helps clients to see
             warning signs of symptoms. During depression, psychotherapy usually works more
             gradually than medication and may take two months or more to show its full
             effects. However, the benefits are often long lasting.




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             Support Groups
             Support groups can be a valuable part of treatment. These groups provide a forum for
             mutual acceptance, understanding, and self-discovery. Participants develop a bond
             with other attendees because they have all lived with mood disorders. People new to
             mood disorders can talk to others who have learned successful strategies for coping
             with the illness. Some of the main support groups include:

                    • National Depressive and Manic-Depressive Association (National
                       DMDA) - the largest illness-specific, patient-run organization in the
                       country.

                    • National Alliance for the Mentally Ill (NAMI) - a nonprofit, grassroots,
                       self-help, support and advocacy organization of consumers, families, and
                       friends of people with severe mental illnesses, such as schizophrenia,
                       major depression, bipolar disorder, obsessive-compulsive disorder, and
                       anxiety disorders.



                        Question 11: How do you think having a close friend or
                        family member with bipolar disorder would affect you?



             Summary
                 • Everyone has ups and downs in mood. Happiness, sadness, and anger are
                    normal emotions and are a normal part of everyday life.

                 • In contrast, bipolar disorder is a medical condition in which people have
                     mood swings out of proportion to things going on in their lives. These mood
                     swings affect thoughts, feelings, physical health, behavior, and functioning.

                 • With this disorder a person sometimes has an extremely elevated mood
                    (mania) and sometimes has an extremely low mood (depression).

                 • In the U.S. more than 2.2 million people have bipolar disorder. Bipolar
                     disorder usually develops between the ages of 16 and 35 but may develop in


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                    a person's forties or even fifties. It is a lifelong disorder, but in between
                    mood episodes, many people can function normally.

                 • Alcohol and other drug abuse are not only common among bipolar patients
                   but also may contribute significantly to treatment resistance and poor
                   treatment outcome.

                 • Some drugs including marijuana, downers, alcohol, and opiates seem to dull
                   the effects of mood swings temporarily, only to cause other symptoms later.
                   Other drugs such as speed and cocaine can enhance manic depression and
                   send people into manic states, often followed by deep depression and
                   psychotic symptoms.

                 • The use of drugs by people with bipolar disorder possibly stems from their
                   discovery of short-term release from the symptoms of mania or depression.
                   The unfortunate reality is that the relief of symptoms by using drugs or
                   alcohol is short-lived and often begins a cycle of substance abuse.

                 • There is no cure for bipolar disorder, but effective treatments are available to
                   stabilize moods and help clients regain and maintain a satisfying and
                   productive life. Some of the most common treatments for bipolar include
                   medication, psychotherapy, and support groups.




             References
             American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders
             (4th ed.). Washington, DC: Author.




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                                         Module 15 Main Points


      Bipolar Disorder is a disorder that consists of very high highs(mania) and very low lows (depression).

      These mood swings affect thoughts, feelings, physical health, behavior, and functioning.

       It is a lifelong disorder, but in between mood episodes, many people can function normally.

      Sometimes people will use street drugs to try to “treat” their Anxiety. There are several problems with
      this plan:
          o Only a short term fix
          o Can make the Bipolar Disorder even worse.
          o Can “hide” other symptoms and problems.
          o Can aggravate the mood swings and make it more difficult to treat.
          o It’s illegal and results in jail and prison.
          o Need more and more to get the same results (tolerance).

      Psychotherapy is also an effective treatment, especially when in combination with medication.

      Support groups exist and can be very helpful.




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                                               MODULE 16
                                        What is Schizophrenia?



                    Instructions to Group Leader:

             One of the main goals of this module is to describe two of the more prevalent
             psychotic disorders that people may experience and to emphasize the benefits
             of treatment with prescription medication instead of substances of abuse.

             You can break this module up into more than one group or skip some
             exercises if you cannot fit it all into one group. Another idea would be to have
             participants complete some of the exercises as homework or with their
             counselors. You can also skip or modify exercises if they are not appropriate for your
             program or treatment population.


             Overview
             This module is intended to provide clients with an overview of schizophrenia and
             schizoaffective disorder, their treatments, and their connection with substance
             abuse. Basic facts about the disorders from the American Psychiatric Association’s
             Diagnostic and statistical manual of mental disorders, fourth edition (1994) are
             reviewed, covering prevalence, diagnosis, and symptoms. Antipsychotic
             medications are also described.


             Schizophrenia
             Schizophrenia is a major psychiatric disorder that occurs in about 1% of the
             population. It typically becomes full blown in the late teenage years or early 20’s and
             often after the individual experiences a period of high stress. The cause is
             unknown but may be related to changes in the amounts of brain chemicals due to
             heredity (genetic factors), early effects of the environment on the developing brain
             (during pregnancy or during birth), or both. Thus, it seems to occur as a result of
             biological and environmental risk factors.




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             People who have schizophrenia may experience periods of time where they lose
             contact with reality in the form of hallucinations (seeing, hearing, or smelling
             things that do not exist) and/or delusions (erroneous beliefs that are strongly held
             in spite of contradictory evidence). They may also experience low motivation,
             poor attention, and inability to experience pleasure. At times, it may be hard for
             people with schizophrenia to tell the difference between fantasy and reality, and
             their symptoms may become so severe that they need to be hospitalized. Because
             there is currently no medical test for schizophrenia, people are diagnosed with the
             disorder through a clinical interview with a trained mental health professional.

                    Question 1: What are the signs and symptoms of schizophrenia?
                    That is, how might a person with it think, feel, and act?


             Symptoms of Schizophrenia (adapted from the DSM-IV, 1994)
             A person must experience some decrease in social or occupational functioning for at
             least a six-month period to be given a diagnosis of schizophrenia. Problems can be
             experienced in school or work, social relationships, or self-care. The symptoms of
             schizophrenia can be divided into three broad groups: symptoms present in people
             with schizophrenia but ordinarily absent in other people (1-4 below),
             symptoms displaying an absence of thoughts, perceptions, or behaviors normally
             present in other people (5-9 below), and other symptoms. A person with
             schizophrenia has some (but not all) of the following:

                 “Positive Symptoms” - refer to things that are present in people with
                 schizophrenia but ordinarily absent in other people. The presence of these
                 symptoms varies over time and include:

                    1. Hallucinations -- seeing, hearing, feeling, or smelling things that are not
                       actually there

                    2. Delusions - false beliefs that others can clearly see are not true (e.g.,
                       believing the television is talking specifically to them or that the
                       government is after them)

                    3. Thinking Problems - talking in a manner that is hard to follow, making
                       up words, or jumping from one topic to the next


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                    4. Odd Behavior - very disorganized or inappropriate behavior (e.g.,
                       untriggered agitation, very disheveled appearance, or inappropriate
                       sexual behavior) or very much decreased reactivity to the environment (e.g.,
                       maintaining a rigid or bizarre body posture like a mannequin or excessive
                       motor activity without observable cause)

                 “Negative Symptoms” - absence of thoughts, perceptions, or behaviors that are
                 present in other people. These symptoms are often stable over time and include:

                    5. Blunted Affect - reduced expressiveness of the face, tone of voice, and
                    gestures; the person may seem like s/he is not experiencing any emotions

                    6. Apathy and Low Motivation - feeling unmotivated to pursue goals or
                    activities, feeling lethargic or sleepy, and having trouble following through on
                    even simple plans

                    7. Loss of Pleasure - feeling little or no pleasure from activities that used to
                       be enjoyable

                    8. Poverty of Speech or Content of Speech - talking a lot but not
                       conveying much information

                    9. Problems with Attention - being easily distractible

                 “Other Symptoms” can include depression and suicidal thoughts, anger and
                 hostility, and rapidly changing mood.

             Schizoaffective Disorder
             Schizoaffective disorder is similar to schizophrenia but involves an additional
             mood component. The symptoms of schizoaffective disorder can be divided into four
             broad categories: “present symptoms” (see 1-4 from the schizophrenia section above),
             “absent symptoms” (see 5-9 from the schizophrenia section above),
             depression, and mania.

             Depression is primarily characterized by a period of depressed mood or the loss of
             interest or pleasure in nearly all activities (see module 2 for a more in depth
             discussion). Mania (described more fully in module 3) can be described as a
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             period of abnormally and constantly elevated, expansive, or irritable mood. It is
             important to note that while everyone feels depressed or irritable or “pumped up”
             from time to time, in both the cases of depression and mania, these symptoms are
             more extreme and last for longer periods of time than is typical for most people.

                    Question 2: What is the difference between schizophrenia and
                    schizoaffective disorder?
                    Question 3: How do you think substance use might affect the symptoms
                    of someone with these disorders?




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              Module 16 Instructor’s version of handout: Case Studies
             Read the following:

             Case Story 1
             Barbara had always seemed a bit “odd in her thinking” to many of her friends and
             family. Her mother had once commented that Barbara reminder her of Barbara’s
             father in that respect. He had been diagnosed with schizophrenia shortly after
             Barbara was born. Barbara liked being different, though, so she didn’t mind being
             thought of as “out there”.

             Barbara’s mother died of a drug overdose when Barbara was 17, leaving her alone.
             It was hard trying to support herself because Barbara had trouble keeping a steady
             job. After a while the bills started to pile up. The stress was too much for her.

             Barbara started hearing voices telling her that things were hopeless and that she was a
             bad person. She was also beginning to suspect that she was under
             surveillance by the FBI because they had gotten a tip that she was keeping a cat in her
             apartment without telling her landlord. At any rate, she was certain they were behind
             her getting fired from her last two jobs.

             She was chronically on edge and felt wired all the time. The voices in her head
             were telling her that Barbara should do awful things to her former boss and then
             kill herself. She knew she didn’t want to do that, but the voices were so loud and
             constantly there. It was impossible to ignore them. Barbara started taking
             barbiturates to soothe herself. At least when she slept she couldn’t hear the voices.

               Question 4: What symptoms of schizophrenia can you identify from the story?
                      Answer: Auditory hallucinations, bizarre beliefs, and paranoia. Being wired all the
               time could be a symptom of schizoaffective disorder with a manic component.


               Question 5: Can you identify any risk factors for schizophrenia from the story?
                        Answer: Family history, high stress period, history of low level symptoms all her life -
               i.e., always having been “odd”




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               Module 16 Instructor’s version of handout: Case Studies


             Read the following:

             Case Story 2
             Marcus had a miserable life. His father was killed several years ago in a drive-by
             shooting when Marcus was fifteen. Since then, his mother had brought a string of
             boyfriends home over the years, insisting that he call them “Dad”. The latest one
             had been a real piece of work. He would come home drunk and beat Marcus’
             mother. If he finished with her before passing out, he’d start on Marcus next. A
             year ago, he’d broken Marcus’ jaw with a baseball bat and put Marcus’ mother in
             the hospital.

             Not surprisingly Marcus looked for any way to escape that he could. Some kids in the
             neighborhood had introduced him to a number of different drugs, and he tried them all.
             His favorite was LSD. He liked watching weird things happen right
             before his eyes and often thought that he had the power to control what
             hallucinations he saw. He knew that if he concentrated hard enough he could make them
             actually happen to his “dad”.
             During a particularly rough period at home, Marcus stayed on LSD pretty much all day,
             every day. He started mixing the LSD with other drugs too. One night his “dad” caught
             Marcus stealing money out of his wallet and threw him down the stairs headfirst. When
             Marcus woke up he was in a hospital under restraint. The nurse told him that he’d been
             babbling for several days about melting walls and scooping out his “dad’s” brains and
             feeding them to a dog.

                 Question 7: What symptoms of schizophrenia can you identify from the story?
                         Answer: It’s unclear whether the hallucinations and his belief about his ability to
                 control them are the result of the drugs, a mental disorder, a head injury, or a
                 combination.

                 Question 8: Can you identify any risk factors for schizophrenia from the story?
                        Answer: His age, experiencing high stress, and possibly drug use.

                 Question 9: Why is it hard to determine exactly what is going on in Marcus’ case?
                        Answer: He started experiencing the symptoms of the mental illness while on
                 drugs.

                 Question 10: How might someone go about figuring out what is going on with him?
                        Answer: Get him off the drugs and see whether his condition changes.



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               Module 16 Instructor’s version of handout: Case Studies

                 Question 7: What symptoms of schizophrenia can you identify from the story?
                         Answer: It’s unclear whether the hallucinations and his belief about his ability to
                 control them are the result of the drugs, a mental disorder, a head injury, or a
                 combination.

                 Question 8: Can you identify any risk factors for schizophrenia from the story?
                        Answer: His age, experiencing high stress, and possibly drug use.

                 Question 9: Why is it hard to determine exactly what is going on in Marcus’ case?
                        Answer: He started experiencing the symptoms of the mental illness while on
                 drugs.

                 Question 10: How might someone go about figuring out what is going on with him?
                        Answer: Get him off the drugs and see whether his condition changes.




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             Module 16 Handout: Case Studies
             Read the following:

             Case Story 1
             Barbara had always seemed a bit “odd in her thinking” to many of her friends and
             family. Her mother had once commented that Barbara reminder her of Barbara’s
             father in that respect. He had been diagnosed with schizophrenia shortly after
             Barbara was born. Barbara liked being different, though, so she didn’t mind being
             thought of as “out there”.

             Barbara’s mother died of a drug overdose when Barbara was 17, leaving her alone.
             It was hard trying to support herself because Barbara had trouble keeping a steady
             job. After a while the bills started to pile up. The stress was too much for her.

             Barbara started hearing voices telling her that things were hopeless and that she was a
             bad person. She was also beginning to suspect that she was under
             surveillance by the FBI because they had gotten a tip that she was keeping a cat in her
             apartment without telling her landlord. At any rate, she was certain they were behind
             her getting fired from her last two jobs.

             She was chronically on edge and felt wired all the time. The voices in her head
             were telling her that Barbara should do awful things to her former boss and then
             kill herself. She knew she didn’t want to do that, but the voices were so loud and
             constantly there. It was impossible to ignore them. Barbara started taking
             barbiturates to soothe herself. At least when she slept she couldn’t hear the voices.

               Question 4: What symptoms of schizophrenia can you identify from the story?




               Question 5: Can you identify any risk factors for schizophrenia from the story?




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               Module 16 Handout: Case Studies


             Read the following:

             Case Story 2
             Marcus had a miserable life. His father was killed several years ago in a drive-by
             shooting when Marcus was fifteen. Since then, his mother had brought a string of
             boyfriends home over the years, insisting that he call them “Dad”. The latest one
             had been a real piece of work. He would come home drunk and beat Marcus’
             mother. If he finished with her before passing out, he’d start on Marcus next. A
             year ago, he’d broken Marcus’ jaw with a baseball bat and put Marcus’ mother in
             the hospital.

             Not surprisingly Marcus looked for any way to escape that he could. Some kids in the
             neighborhood had introduced him to a number of different drugs, and he tried them all.
             His favorite was LSD. He liked watching weird things happen right
             before his eyes and often thought that he had the power to control what
             hallucinations he saw. He knew that if he concentrated hard enough he could make them
             actually happen to his “dad”.
             During a particularly rough period at home, Marcus stayed on LSD pretty much all day,
             every day. He started mixing the LSD with other drugs too. One night his “dad” caught
             Marcus stealing money out of his wallet and threw him down the stairs headfirst. When
             Marcus woke up he was in a hospital under restraint. The nurse told him that he’d been
             babbling for several days about melting walls and scooping out his “dad’s” brains and
             feeding them to a dog.

                 Question 7: What symptoms of schizophrenia can you identify from the story?



                 Question 8: Can you identify any risk factors for schizophrenia from the story?




                 Question 9: Why is it hard to determine exactly what is going on in Marcus’ case?



                 Question 10: How might someone go about figuring out what is going on with him?
                        .


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               Module 16 Handout: Case Studies

                 Question 7: What symptoms of schizophrenia can you identify from the story?


                 Question 8: Can you identify any risk factors for schizophrenia from the story?



                 Question 9: Why is it hard to determine exactly what is going on in Marcus’ case?


                 Question 10: How might someone go about figuring out what is going on with him?




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             Connection Between Schizophrenia and Substance Abuse, and Schizoaffective
             Disorder and Substance Abuse
             Sometimes people with these disorders start taking street drugs in order to reduce their
             symptoms. This practice, commonly known as self-medicating, can work in the short-
             term; however, it may serve to increase or worsen symptoms later on. Additionally,
             individuals who treat their symptoms with drugs run the risk of becoming addicted to
             them. In this case, having schizophrenia or schizoaffective disorder can be a risk factor
             for substance use problems.

             Unlike street drugs, the common medications used to treat schizophrenia and
             schizoaffective disorder are not addictive. Additionally, use of illegal substances
             can lead to a variety of life problems (e.g., legal problems), which can cause stress
             for the individual and family and diminish effective coping with the mental health
             problem. As such, substance use can be a risk factor for the onset or worsening of
             schizophrenia or schizoaffective disorder in people already at risk for developing
             the disorders.

             Antipsychotic medications are specifically intended to treat schizophrenia and
             schizoaffective disorder. They are legal solutions to the problem that won’t set the
             individual up for a number of other potential problems (e.g., legal problems,
             risking making symptoms worse in the long term). Although they are better suited
             to treating schizophrenia and schizoaffective disorder, antipsychotic medications can
             cause a number of side effects. As such, anyone taking them should be working
             closely with a doctor who can help treat any side effects that might arise.



                       Question 11: What are the benefits and drawbacks of
                       taking antipsychotic medications over self-medicating with
                       drugs?




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             Psychotherapy & Other Treatments


             Treatment
             Both disorders may be treated with a variety of psychotherapies such as social
             skills training or cognitive-behavioral therapy (described in more detail in module
             1), but most likely these treatments would also be combined with medication.
             Supported employment and case management may also be beneficial. Because this
             illness affects not just the individual with the disorder but also the whole family,
             family therapy may help decrease stress and help family members cope as well.




             Medication

             Although the symptoms for both disorders tend to improve with age, schizophrenia
             and schizoaffective disorder are life long. As previously stated, they are often
             treated with medications called antipsychotics, which help reduce their symptoms.
             People with schizoaffective disorder may also receive medications that stabilize
             their mood fluctuations.

             Antipsychotic medications are effective at reducing the “present symptoms” such as
             hallucinations, delusions, and bizarre behavior. Furthermore, these medications can
             sometimes reduce the “absent” symptoms such as social withdrawal and poor attention.
             In addition to lowering their severity, antipsychotics can help to prevent relapses of
             these symptoms.

             Sometimes the effects of these medications are quite rapid, with an improvement in
             symptoms being noted in a few days; but they need to be taken for several weeks
             to reduce symptoms significantly. If a person experiences a relapse of symptoms,
             the dosage of antipsychotic medication may be temporarily increased.
             Antipsychotics are not addictive. People taking these medications do not develop
             tolerance, requiring higher doses over time. However, use of these medications
             should be monitored by a physician because there is the potential for overdose.




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             Antipsychotic medications, like other drugs for treating other illnesses, can cause
             undesired side effects. Although other more serious side effects can occur, the most
             common side effects of traditional antipsychotics include:

                    • Drowsiness
                    • Muscle stiffness
                    • Dizziness
                    • Dry mouth
                    • Mild tremors
                    • Restlessness
                    • Increased appetite
                    • Blurred vision
                    • Sexual difficulties

             Not all people taking these medications experience side effects. In many cases the side
             effects are temporary, especially if they are treated with side effect
             medications. They also can be addressed by reducing the medication dosage or
             changing to a different type of antipsychotic.

             Like the antipsychotic medications, though, side effect medications are potentially
             dangerous and should only be taken under the supervision of a physician (e.g.,
             Benadryl, used to treat some side effects, can be addictive.). In any case, the best
             course of action is to consult with a physician when side effects occur. It is also
             important to be honest with the physician about any other medications or street
             drugs that a person is taking or plans to take while using these medications.

             The following table lists common antipsychotic medications, their average dosage
             ranges, and their possible side effects. While these are common antipsychotic
             medications, they are not always prescribed only for thought disorders. These
             medications have a variety of other uses and may be prescribed for those purposes
             as well.




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                Traditional Antipsychotic Medications

                Type of Drug       Brand           Chemical           Average      Possible Side Effects
                                   Name            Name               Dosage
                                                                      Range
                                                                      (mg/day)*
                                   Clozaril**      Clozapine            200-900    Dry mouth,
                                                                                   drowsiness, blurred
                                   Haldol***       Haloperidol           1-40      vision, constipation,
                                                                                   urinary retention, nose
                                   Loxitane        Loxapine              4-250     bleeds, dizziness

                                   Mellaril        Thioridazine         50-600

                                   Moban           Molindone            15-250

                                   Navane          Thiothixene           6-60

                                   Prolixin*** Fluphenazine              1-40

                                   Risperdal** Risperidone                1-8

                                   Serentil        Mesoridazine         25-300

                                   Seroquel        Quetiapine          150-750

                                   Stelazine       Trifluoperazine       4-60

                                   Thorazine       Chlorproma-         50-1250
                                                   zine

                                   Trilafon        Perphenazine          8-64

                                   Zyprexa         Olanzapine            5-20


               *    Estimated dosage ratio in relation to Thorazine

               ** Clozaril and Risperdal have different mechanisms of action than the other
                  antipsychotic medications, and therefore their dosage range is not comparable.

               *** Also available in long-acting injections



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             ADC Treatment Curriculum




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                Medications for Extrapyramidal Side Effects of Traditional Antipsychotics

                Type of Drug      Brand       Chemical Name Average         Possible Side Effects
                                  Name                        Dosage
                                                              Range
                                                              (mg/day)
                Anticholinergic   Artane      Trihexyphenidyl   5-15        Dry mouth, constipation,
                                                                            blurry vision, drowsiness,
                                  Benadryl    Diphenhydramin     50-300     urinary retention, memory
                                                                            loss
                                  Cogentin    Benztropine         0.5-8

                                  Kemadrin   Procyclidine         5-20

                Dopamine          Symmetrel Amatadine            100-400 Increase in “present”
                agonist                                                    symptoms

                Benzodiazepines   Ativan      Lorazepam           2-10      Drowsiness, psychomotor
                                                                            impairment, memory loss,
                                  Compazine Prochlorperazine     15-150     psychological and
                                                                            physiological dependence,
                                  Klonopin    Clonazepam         0.5-16

                                  Librium     Chlordiazepoxide    5-100

                                  Valium      Diazepam            2-40

                                  Xanax       Alprazolam         0.75-4




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             Summary
                 • Schizophrenia and schizoaffective disorder are mental health issues that
                   seem to occur as a result of biological and environmental risk factors.

                 • Both disorders can involve “present symptoms” (e.g., hallucinations and
                   delusions) and “absent symptoms” (e.g., blunted affect and poverty of
                   speech), but schizoaffective disorder has an added mood component
                   (depression or mania).

                 • Use of street drugs can be a risk factor for developing or worsening
                   schizophrenia and schizoaffective disorder by causing life problems that
                   increase a person’s stress level and decrease coping.

                 • Schizophrenia and schizoaffective disorder can be risk factors for substance
                   use problems if people use street drugs to reduce their symptoms (known as
                   self-medication).

                 • Medications called antipsychotics are typically prescribed by physicians to
                   treat the symptoms of schizophrenia and schizoaffective disorder.

                 • Antipsychotic medications are not generally addictive and do not cause the
                   user to develop tolerance to them. However, there is the potential for
                   overdose.

                 • Antipsychotic medication may cause side effects that are treatable with other
                   medications or by reducing dosage or changing medications.

                 • Like most medications, antipsychotic medications and side effect
                   medications are still potentially dangerous. Thus, it is important to work
                   with a physician when taking them and to be honest about other medications or
                   street drugs that the patient may be using or plans to use while on these
                   medications.

             References
                    American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
             disorders (4th ed.). Washington, DC: Author.



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                                          Module 16 Main Points


      Schizophrenia is a major psychiatric disorder.
      Schizophrenia has both positive and negative symptoms.
       Positive Symptoms refer to things that are present in people with schizophrenia but ordinarily absent in
      other people.
      Negative Symptoms refers to- absence of thoughts, perceptions, or behaviors that are present in other
      people.
      Schizoaffective disorder is similar to schizophrenia but involves an additional mood component. The
      symptoms of schizoaffective disorder can be divided into four broad categories:
         o Present symptoms
         o Absent symptoms
         o Mania
         o Depression

      Sometimes people will use street drugs to try to “treat” their Anxiety. There are several problems with
      this plan:
          o Only a short term fix
          o Can make the Bipolar Disorder even worse.
          o Can “hide” other symptoms and problems.
          o Can aggravate the mood swings and make it more difficult to treat.
          o It’s illegal and results in jail and prison.
          o Need more and more to get the same results (tolerance).




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                                                 MODULE 17

                                              Distorted Thinking

             Objective: To help participants understand and manage thinking and depression.


                       Please review the definition of Sadness and Depression from

                       Module 11 Say In Your Own Words:

             Now let’s talk about “Cognitive Distortions (thinking errors) & Depression”.

             ‘Cognitive Distortions’ are simply the errors we make when we think about
             situations. Let’s talk about them now.

                        Please pass out the following handouts to participants:
             “Cognitive Distortions”; and “Cognitive Distortions Related to Recovery.”
              After each term ask members to join in and give examples, ask questions etc.)

             • All-or-Nothing Thinking
             • Over-generalization
             • Mental Filter
             • Discounting or Disqualifying the positive
             • Jumping to conclusions
             • Catastrophizing or minimization
             • “Should” statements
             • Labeling or name calling
             • Personalization

             Remember the list of depressive symptoms we talked about before? (please refer back to the list) .
             The core thinking (cognitive) structures in depression are hopelessness, helplessness and
             worthlessness which are supported by these distortions! By learning how to repair these thinking
             errors, you can combat the ‘hopeless-helpless-worthless’ syndrome. It has been found that this
             kind of ‘cognitive work’ is as important as medications in the treatment of depression.




                       Ask participants to keep a diary of their Cognitive Distortions.

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               Module 17 Handout /Homework: Cognitive Distortions

               COGNITIVE DISTORTIONS

             1.    All-or-Nothing Thinking: This happens when you see things as either ‘all one
                   way or all the opposite way’.          When thinking this way there is no middle
                   ground—no compromise. If your performance falls short of perfect, you see
                   yourself as a failure. "I'm a total failure because I didn't finish high school".

             2.    Overgeneralization: This occurs when you see a single negative event as a
                   never-ending pattern of defeat. "I broke up with my girlfriend; I'll never have
                   another relationship".

             3.    Mental Filter: You pick out a negative detail and dwell on it completely.
                   Your ‘reality’ becomes darkened (like the drop of ink that discolors the entire glass
                   of water). "The car wouldn't start, my whole day is ruined".

             4.    Discounting the Positive: You reject positive experiences by insisting they
                   "don't count". In this way you work to maintain a negative belief that is
                   contradicted by your everyday experience. "I may have gotten a good job last year,
                   but I was just lucky".

             5.    Jumping to Conclusions: You make a negative interpretation even though
                   there are no definite facts that convincingly support your conclusion.  “My
                   boss has on a suit today. That means something bad is going to happen.”

             6.    Mind Reading: You arbitrarily conclude that someone is reacting negatively
                   to you, and you don't bother to check this out. "My boss didn't say hi to me this
                   morning, I know she's mad at me".



             7.    Fortune Telling: You anticipate that things will turn out badly, and you feel
                   convinced that your prediction is an already established fact. (“I know that I
                   will fail the GED math section. I’m not taking the test.”

             8.    Magnification (Catastrophizing) or Minimization: You exaggerate the
                   importance         of things (such as goof-up on your part ; another person’s
                   achievement) , or you           inappropriately shrink things until they appear
                   tiny (your own desirable qualities;         another person's imperfections).

                   Magnification: "I can’t type, I'm a failure."
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                   Minimization: "I may have a H.S. degree, but it's not worth much these days".



               Module 17 Handout /Homework: Cognitive Distortions



             9.    Emotional Reasoning: You assume that your feelings reflect the way things
                   are. "I know that everyone feels the same way that I do about taxes."

             10. “Should" Statements: You try to motivate yourself with ‘shoulds’ and
                 ‘should-nots’. You also expect other people to ‘should’ or ‘should-not’ behave in
                 certain ways!. Some results of these demands are guilt, shame, resentment,
                 rebelliousness, anger, disappointment, depression etc. “I should organize a
                 party because no one else will.”

             11. Labeling or Name-Calling: Instead of saying, "I made a mistake", you say
                 "I'm a fool". When applied to other people, whose behavior irritates you, you say,
                 "He's a jerk".

             12. Personalization: You see yourself as the cause of some event over which you
                 were not responsible or had no control. "If I had paid more attention to my
                 brother, he wouldn't have started using crack."




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              Module 17 Handout: Cognitive Distortions Related to Recovery

             1.      My symptoms (sadness/depression, fear/anxiety, anger etc.) are too uncomfortable and
                     they shouldn't be this uncomfortable! I shouldn’t have to deal with them.

             2.      There should be an EASY, MAGICAL WAY to change!

             3.      If I understand how I got this way, I'll easily and magically change, with no effort
                     on my part.

             4.      My therapist should change me!

             5.      I've been this way TOO LONG to change!

             6.      I can only change by venting my feelings (screaming, yelling, blaming others/moaning
                     and whining), and this will magically change things.

             7.      Therapy is too boring. It should be more interesting.

             8.      Therapy is too rigorous if it requires me to DO SOMETHING.

             9.       I'll only change if my therapist and the rest of the world loves me, otherwise,
                      it's TOO HARD.


             CHALLENGE THESE IRRATIONAL BELIEFS

                  1. Ask yourself, "WHY is it TOO HARD?" (Answer: It never is, it can be very
                     hard, but never too hard.)

                  2. Prove that you CAN'T STAND being feeling how you feel. (You're standing it now,
                     so that proves you CAN stand it.)

                  3. Where is the evidence that you should only get just so much frustration and no more?
                     (Answer: There is no evidence. No cutting-off point for frustration. Whatever frustration
                     you have, that's what exists.)    -

                  4. No one else can change you or magically make things easy for you.




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                                          Module 17 Main Points


      There are some ways of thinking that can increase your likelihood to commit another crime or relapse.

      Some ways of thinking can make depression symptoms worse:


                       All-or-Nothing Thinking
                       Over-generalization
                        Mental Filter
                        Discounting or Disqualifying the positive
                        Jumping to conclusions
                       Catastrophizing or minimization
                       “Should” statements
                       Labeling or name calling
                        Personalization




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                                                 MODULE 18

                                       How to Recognize a Problem
                                      Recognize a Pr
             Objective: To improve problem identification skills

             Content: This session will help the individual to recognize a problem when it
             occurs, and to better anticipate when problems might occur.

             Say In Your Own Words:

                     What does ‘improve problem solving’ mean? Ask the group what they think
                     problem solving is - when have they recognized a need to use a problem solving
                     skill?

                     What is a problem? How would you know one if you saw it? Problems are
                     typically defined by saying that they are a situation or circumstance where a need,
                     belief, or expectation is not being met.

                     Can anyone give an example of this? Ask the person offering the example to
                     discuss what the need / belief / or expectation is associated to this problem. So,
                     how do you recognize problems in your life? What are some signs that
                     something is happening?

             Sometimes the signs of a problem are obvious (i.e., having had a big fight) and
             sometimes they are subtle. When problems are subtle you have to look for other
             indicators that a problem exists. This involves some degree of self-
             awareness. This means looking at what is not quite right about your life or how you
             may be behaving differently than you did in the past.

             A behavioral indicator that a problem exists might be that you want to stay in bed more
             often. An emotional indicator might be the return of a powerful feeling.

             You might try to deny that a problem exists. When has this happened? How did you
             try to ignore the problem? Did the problem get worse? Sometimes you might have a
             strong impulse to ignore the problem. Though you might have an example where the
             problem went away when you ignored it, most of the time, problems get worse.

             Another way to identify a problem is to ask yourself whether someone else
             objects to what you are doing - is your activity either socially unacceptable or illegal?
             You might not agree at the time that this activity is a problem, but it is likely that it
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             will be building up to a big problem for you.



                                         Module 18 Main Points


      To solve a problem, you must first recognize/ understand that there IS a problem.

      A problem exists when a need, expectation or belief is not being met.

      If the problem is not obvious, you sometimes have to look to find it. Things that might indicate a
      problem:

          o Your own behavior- Has it changed? If so, why? What is driving the change?

          o Input from other people- Are other people telling you that there is an issue? Sometimes others can
             see what we don’t want to look at.




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                                                MODULE 19
                                              Stressful Events

             Objective: To become aware of stressful situations and re-label them as problems to be solved.

             Content: This session focuses on perceptions involved in the evaluation of
             stressful events.

             Say In Your Own Words:

             Sometimes we feel that our problems are so large that we are overwhelmed.
             One “trick” of improving problem solving is that we teach ourselves to break problems
             down so that we are not so overwhelmed and we can make a little progress on solving
             the more complex problems that we confront over a period of time.

                    Break down a simple task into component parts with the group’s help.

             You might think of your problems as stressors. How do you know when you are
             feeling stressed? What kinds of feelings go along with this? Do you even think of
             yourself as feeling stressed at different points in time?

                    Allow time for discussion on the different types of circumstances and
                    interactions that people find as stressful.

             When you find that something is stressful what do you see is your role in
             thinking about it as a stressful event? Is there anything in the way that you think
             about it that makes it seem more stressful than it has to be?

                     Lead the discussion into perceptions and how they can influence what people
                 evaluate as stressful. Give examples to show differences between individuals, i.e., looking at
                 events that one person might enjoy while another might feel is stressful. This may include
                 telling jokes in front of a group, riding a ferris wheel, solving a page of math problems,
                 writing a story.

             The goal of improved problem solving is to have fewer events that you view as
             stressful and to feel that more situations are under your control.

             It is important to feel that you are able to solve your problems and that you have
             choices in how to solve problems? What do I mean by this?

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                    Essentially the group leader is trying to communicate that there is often
                    more than one solution to a given problem.




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             Module 19 Handout: Breaking Down the Problem

             Problem- “I need to clean the kitchen and it is a complete mess. It is so dirty that it seems
             overwhelming.”
             1. Gather all of the dirty dishes and place them in sink with soap and water.
             2. Wash the dishes, dry them and put them away.
             3. Soak the pans.
             4. Wipe down the tables, countertops and stovetops.
             5. Sweep and mop the floor
             6. Take out the garbage.
             7. Scrub the dirty pans, dry them and put them away.
             8. Give one final wipe down to counter.


             What first seemed like an impossible task was really only a series of smaller and doable
            steps.
             Remember, the old joke-
             How do you eat an elephant?
             One bite at a time.




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                                          Module 19 Main Points


      Stress often happens because how we are looking at a problem/ situation.

      Many times something will seem “too big” for us to handle.


       The best way to deal with it is to break it down into small bits that you can handle.

      One Day at a Time—One Piece of the Problem at a Time




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                                             MODULE 20
                                Analyzing and Responding to Problems


             Objectives: 1. To begin to evaluate themes as to when problem events occur
             2. To begin to plan thoughtful responses to problems.


             Content: This session allows participants to begin to break down problem
             situations into their component parts. It encourages them to analyze all of the
             problem variables in the situation and understand the complexity of it before they
             make a decision to act.

             Say In Your Own Words:

             This morning we want to start by looking at how you decide whether
             something is a problem in your life. We want you to start by evaluating what are the
             circumstances surrounding when a problem situation arises.

             Think about WHO is involved in the situation. Is it someone that you have regular
             conflicts with? Are there several people? Are they directly involved in the situation
             or just present?

                    Develop an example with the group that can be added to as the discussion
                 progresses. It may involve an argument between two people over a topic of the
                 group’s choice, or another topic at the group leader’s discretion.

             If another person is directly involved, it is someone that you have strong
             feelings about? Is there a quality about them that rubs you the wrong way? Do you
             expect and anticipate that you will have problems with them?

             Next ask yourself WHEN the situation has been occurring. We can get a lot of
             information from that - like the time of day or what day is it? There are sometimes more
             options for problem solving when events occur at, say, 3pm versus 3am.

             WHERE do a lot of problems occur? Is it in someone’s house, on the street,
             etc? Your responses to problems may also be limited by where something occurs.

             Let’s stop and discuss why it is important to evaluate who, when and where problems
             are occurring.


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             Say In Your Own Words:

             Now we can get to the WHAT of what is happening in any problem situation.
             The what is complicated because we usually have feelings about how
             something ‘should’ have occurred. There can also be a lot of distortion in how
             people perceive situations. What do I mean by this -- can anyone give an
             example?

             For example, when two people observe an event, like a car accident, for
             example, why is there often some discrepancy between the observer’s stories?

                    Discuss this as being related to the perspective that the person has, when they
                 arrived on the scene, and what their biases might be depending on who the driver’s
                 might be. Do they hold stereotypes that might make them feel that one driver over
                 another might have caused the accident, if they did view the seconds before the
                 crash?

             In any problem situation you might have biases about how a situation might
             unfold that you bring the situation before it occurs? Does this make sense to
             you?

             Can you think of an example where you expected that something bad was going to
             happen and it did?

             Is it ever possible that your expectation of something bad happening could
             contribute to the event actually occurring?


                    Discuss self-fulfilling prophecies. Talk with the group about how not
                    believing they can make good things happen will cause them to limit their
                    responses to problems or negative events.

             Discussion Topic: Beginning to Generate Solutions


             When you decide that something is a problem, how do you attack it? How do you
             generate solutions to a problem? Think of a very simple problem and how you would
             attack it. What would be the simplest solution to the problem? Remember we are
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             always going to focus on socially acceptable and legal solutions in our examples.




                    Generate discussion from the group on very basic examples of problem
                    solving that are affectively neutral. For example, problem= cold; solution=
                    put on a sweatshirt.

             One method for generating solutions to problems is called BRAINSTORMING. This is when you
             try to think of all possible solutions to a situation. When you are brainstorming don’t stop to
             evaluate whether each solution is socially acceptable, or legal, or whether the solution is ‘smart’.
             We will do that in the next step.

             After you have generated a list of solutions, you can then evaluate which are the best
             ones for you in the long run. After the list has been narrowed you would go on to
             think about the “action steps” that you might implement to gather more information or
             to solve the problem.

               For example:

             You are not sure that your medication is helping your symptoms. Your

             Brainstorm might be:

             1. Continue taking it for some time to see if symptoms improve
             2. Ask a nurse about how long you should take it before symptoms should
                     improve
             3. Ask to meet with the psychiatrist about what symptoms the medication
                     attacks



                    Offer the following as maladaptive alternatives:

             1. Stop taking the medication
             2. Use street drugs to help relieve symptoms.

                    Which of these solutions would work for you? What additional
                    problems might be created depending on the decision that you make?
                    Lead the discussion on this topic.

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                                          Module 20 Main Points


      To decide is something is a problem first ask- Who? When? Where?

      Then ask- What?

      When asking “What?” try to be unbiased. Maybe ask someone else to help you look at situation.

      We can sometimes affect the outcome of a situation by the way that we view and approach it.

       A self-fulfilling prophecy is when our view causes an outcome to occur. For example, I convince
      myself that I am not going to get the job before I even go to the interview because no one will give a
      felon a chance. So, I end up going into the interview with an angry/hostile attitude. I don’t get the job. I
      don’t get the job because of my attitude not because of any bias on the interviewer’s part.




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                                               MODULE 21
                                        Solving Real Life Issues


             Objective: To move the discussion of problem solving into the realm of personal experience.


             Content: This session allow the participants to generate problems and solutions to their
             own “real life” issues.

             Say In Your Own Words:

             Today we want to take each of the methods of problem solving and run through
             several examples that may be relevant to your situation.

             What we must consider, over and over again, in our discussion of problem
             solving, is that we need to think before we act. We think before we act most of the time,
             but sometimes, especially if something is pushing our buttons, we
             might act before thinking. Most of the time this leads to negative
             consequences.

                    Sometimes we use the phrase to “react impulsively”. What does this mean
                    to you? Lead a discussion as to why impulsive behavior often leads to negative
                    consequences.

             Let’s talk about some of the specific problems that you might confront in a given
             day. Then we will apply each of the alternative methods of problem solving in our
             discussion.

             Problem: Boredom

             When someone is bored, we know that they are at risk for making decisions that may
             be impulsive and lead to negative consequences.

                    Let’s brainstorm some responses to being bored. Lead brainstorming.




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             What are the consequences of the solutions that you have recommended?

             Okay, now let’s change our frame of reference. If someone else was bored what
             would you tell to do? How is this different from what you would tell yourself and
             why?

             Third method: What have you done in the past when you were bored, that didn’t
             result in you getting into trouble?

                    Continue to generate examples from the group. In this population we have to
                    focus the participants on being able to observe their actions and move away from
                    impulsivity or, alternatively, passivity.


             Say In Your Own Words:

             We have been focusing on identifying problems and beginning to generate
             solutions. Now we need to focus on having a ‘plan of action”. You can
             generate all of the possible solutions in the world -- but it won’t do you any
             good if you can’t choose between alternatives and evaluate the consequences of your
             choices.

             So the final stage of problem solving is to:

             1. Choose a solution
             2. Implement a plan of action
             3. Evaluate your choice.

             Why is evaluating your choice important?

             If you try to solve a problem and the solution that you’ve chosen is not working,
             then you must be able to see that and choose another solution. Otherwise you might
             again feel frustrated, and make impulsive choices to reduce your stress or
             frustration.

             Alternatively, how do you do you know that a solution is working?

             What are some other common problems that you might share with the group?


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             Examples:

             •      Having difficulty making friends - recognizing the impulse to hang out
                    with the people whom encouraged you to use drugs.

             •      Dealing with medication side effects.

             •      Being discouraged by a self-help group member from taking your
                    medication.

             •      Thinking about stealing to get money to buy drugs.

             •      Losing a benefits check.

             •      Missing an appointment with your psychiatrist - fearing that s/he won’t
                    see you again.


                    Go through each of these examples and generate solutions. Confront
                    maladaptive solutions. Discuss the consequences of impaired decision-making,
                    impulsive decision making in terms of short and long-term consequences.




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             Module 21 Handout: Healthy Decisions
             The problem is:




             Brainstorming of possible solutions:




             Top 3 solutions:
             1.
             2.
             3.




                            Solution #1
          + of solution            - of solution




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              Module 21 Handout: Healthy Decisions




                            Solution #2
         + of solution             - of solution




                            Solution #3
         + of solution             - of solution




               Of the 3 solutions, which is your best option?

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                                          Module 21 Main Points


      Identifying that you have a problem and thinking of solutions is a good start but it is not enough.

      Solutions need to be realistically evaluated. What is good about the solution? What is bad about the
      solution?

      After you decide on and begin to use a solution, you must sometimes go back and re-evaluate the
      solution.

          o Is it working the way that you expected?

          o Did it work at first but now longer works?

          o Has a new and better solution become available?




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                                                MODULE 22
                                               Craving Drugs

              Objectives: 1. In this group we will discuss the idealization of drug use and it’s association
                   with only positive life events and social circumstances. 2. The decision to use prescription
                   medication will be discussed.


             Say In Your Own Words:

             Has anyone heard of the term “selective memories”? What are these?

             Ask the group if they have ever heard of "Euphoric Recall" or "Idealizing the
             High". Can anyone define it? (i.e., selective forgetting, remembering only those
             good feelings or memories, and blocking out all the negative aspects of using).

             Make sure to comment that this is not unlike how we remember most of our
             memories, recalling only certain elements--perhaps either all good or all bad.

             Think about how you have remembered events in the past. Have you
             remembered only the good elements or, perhaps just the bad things that have happened?
             Who can describe having had this type of memory, where events have been selectively
             remembered?

                    Discuss why a desire for euphoria may be related to their experience of
                    depression or other mental illness. What are other safer alternatives that may
                    also increase their mood? Generate some ideas from the group.


             Discussion Topic: Using Prescribed Medication Versus Self-Medication.

             You will discover that some people who support a “self help” model of
             recovery do not believe that you can (or should) take medication for your
             mental illness. Some people will challenge your use and not consider you
             “recovering”.      This is an important concept for you to understand because
             people will challenge your decision to take medication for your psychiatric
             disorder.

             You should always be clear with yourself and others that you are taking your
             PRESCRIPTION medication for the purpose of controlling and relieving your symptoms
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             of mental illness, that you take it under supervised conditions, and in consistent, regular
             doses.




             This is very different than uncontrolled, irregular, and excessive use of alcohol or illicit
             substances. These are two very different behaviors; one is health
             promoting, the other is not.

             Finally, just because some illicit substances are sometimes prescribed, such as the very
             rare instances in which marijuana is for the treatment of glaucoma; this does not validate
             your use of this substance in some way to treat your emotional pain. These substances
             are NEVER prescribed for the treatment of emotional or psychiatric problems.


                      Open this for discussion. Hopefully, the group will bring up the following
                      points (If not bring up these points:

             1.       Best decisions are made when you are clean or drug-free. If you're
                      high, you can't think clearly enough to ensure that you will resist your problem
                      substance. These days, it is very often true that people are using several
                      substances simultaneously.

             2.       Using other drugs may remind you of the times you used to use that
                      drug along with your problem substance. This could set off powerful
                      urges and cravings.


             3.       Reinforce that negative moods can be changed in other ways than
                      through the use of alcohol/cocaine/marijuana. If you continue to rely on
                      alcohol or an illicit substance to help yourself feel the way you want to feel, you
                      are NOT in recovery.

             4.       Using other drugs will likely set you up to become addicted to other
                      substances.

             5.       You should be prepared for comments like: Using prescription drugs is
                      "just another kind of dependence."




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             Module 22 Handout: Selective Memories



             Situation: You are thinking about getting a dog from the shelter. You think
             about the dog that you had a few years ago.

             You remember:
                    How he was such a nice dog.
                    How he used to greet you when you came home.
                    The fun you had playing with him at the park.
                    How he used to curl up at he end of your bed and keep your feet warm.

             You fail to remember:
                    How he chewed up your expensive work boots.
                    How you had to take him out for a walk- even when you were sick or tired
                    and did not feel like doing so.
                    How expensive it was to feed him and take him to the vet.
              In other words, you use selective memory and only remember the good things about
              owning dog. If you make a decision based only on the good factors, why wouldn’t you get
              another one? This is not a healthy or safe way to make decisions.

              Let’s apply this to your drug use. If you only think about the high and the fun, then what
              reason to do you have to not use. It is vital that you also remember the not so good things
              about substance use.

              For me the not good things about using drugs are:
              1.

              2.

              3.

              4.

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              5.




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                                          Module 22 Main Points


      Sometimes our minds play a trick on us and only remember the good or bad about a situation.

      When you only remember the good things about using illegal drugs, you are engaging in “euphoric
      recall.”

      Euphoric recall is dangerous because if there were only good things bout using drugs, then the only
      logical choice would be to use drugs.

      Sometimes we use the “mind trick” to convince ourselves that what we really want to do is in fact the
      best solution. This can be a big factor in our decision to “self medicate”.

          o I want to keep drinking. I only look at the fact that when I drink and am drunk, I feel happy and
             forget my problems. I fail to think about the hangovers, the DUI charges, the family fights, etc.

          o When offered a legal prescription to treat my depression. I only remember the bad things about
             medication. I only remember that it made me gain weight or that it made me have hard time
             falling asleep. I fail to think about the fact that it allowed me to function every day, complete
             parole and stay out of prison.




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                                                   MODULE 23
                                                   Triggers

               Objectives: 1. To answer the question: What is craving? 2. To help participants
               understand what a trigger is and how it can lead to relapse.

                 Content: This session is designed to introduce ways of coping with
                 temptations, cravings, and urges including reducing exposure to high-risk
                 situations and other “triggers.”

                 Say In Your Own Words:

                 Even if you have been clean for a long time, you still may experience
                 episodes of craving. Things you see in the environment that remind you of
                 substances can trigger cravings. They may also be associated with stress, negative
                 emotions, and loneliness.

                 Craving can be an unpleasant reaction. It may include tightness in the stomach or
                 feeling nervous through your body. You may have increased thoughts of
                 substances, fantasies about how good you would feel if you used, memories of
                 times that you used in the past, and the feeling that you believe that substances
                 will provide for you.

                        The therapist can solicit personal comments from participants as they
                        share what craving is like for them. The important point is that craving
                        is unpleasant and it motivates the urge to reduce that unpleasantness.
                        Using again is one way to do that. Using coping skills is another way to
                        do that.

                 Fortunately, craving and urges are time limited; that is, they usually only last for a
                 few minutes, or at most a few hours. Rather than increasing steadily, cravings are
                 more like a wave: They peak after a few minutes and then die down. Craving
                 becomes less frequent and less intense as you learn to cope with them.




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                       The easiest way to reduce craving is to reduce your exposure to
                       triggers and high-risk situations. Common triggers include:

                       Write on flip chart, blackboard, or overhead:

                 1. Exposure to alcohol or drugs themselves.
                 2. Seeing other people using.
                 3. Contact with people, places, times of day, and situations commonly
                 associated with using (parties, bars, friends, weekends, before dinner,
                 etceteras).
                 4. Particular types of emotions such as frustration, fatigue, feeling stressed
                 out. Even positive emotions such as elation and feelings of accomplishment
                 can be triggers.
                 5. Interpersonal stress.


                 Some triggers are hard to recognize because they may not be “in your
                 face.” Triggers can affect all of yours senses. What we are trying to find out
                 is what kinds of things are triggering or maintaining your substance use.




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             Module 23 Handout: Triggers

             Things that have in the past or may in the future trigger my drug use:

             Sights (ex. seeing someone shoot up)-
             1.
             2.
             3.
             4.
             5.

             Sounds (ex. certain music that I used to listen to while getting high)-
             1.
             2.
             3.
             4.
             5.

             Smells (ex. smell of burning rubber)-
             1.
             2.
             3.
             4.
             5.
             Touch (ex. the feel of sex because I always got high before having sex )-
             1.
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             2.
             3.

             Module 23 Handout: Triggers


             4.
             5.

             Taste (ex. the taste of Taco Bell because I always went there when I was high)-
             1.
             2.
             3.
             4.
             5.

             Feelings (ex. bored because I use when I am bored)-
             1.
             2.
             3.
             4.
             5.

             Thoughts (ex. “staying clean is too hard”)-
             1.
             2.
             3.
             4.
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             5.




                         The therapist should ask:

                  •   In what kinds of situations do you use? What are your triggers for using?
                  •   Can you give a specific example—a relapse story?
                  •   Can you remember your thoughts and feelings at the time?
                  •   What were the positive consequences of using?
                  •   What were the negative consequences of using?




                         The participants should be handed a copy of the Self-Monitoring
                         Record and asked to take time once a day to record episodes of
                         craving and urges to use substances.




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             Module 23 Homework Handout: Self Monitoring Record




      Trigger                Thoughts/               Behavior              + Consequences         - Consequences
                             Feelings

      What caused my urge?   What was I thinking &   What did I do then?   What positive things   What negative things
                             feeling?                                      happened?              happened?




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                                            Module 23 Main Points


      It is important to remember that cravings and urges are time limited!

      Whenever possible, it is best to avoid things that trigger your cravings and urges.

      Triggers can affect any of your senses: touch, taste, smell, hearing and sight.

      Common triggers include:

          o    Exposure to alcohol or drugs themselves.

          o    Seeing other people using.

          o    Contact with people, places, times of day, and situations commonly associated with using
              (parties, bars, friends, weekends, before dinner, etc.).

          o Particular types of emotions such as frustration, fatigue, feeling stressed out. Even positive
            emotions such as elation and feelings of accomplishment can be triggers.

          o    Interpersonal stress




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                                               MODULE 24
                                             Avoiding Triggers

                Objectives: 1. To re-emphasize the importance of identifying triggers to use.
                2. To brainstorm ways to avoid exposure to those triggers.


                 Content: This session should be designed to help participants identify their
                 personal triggers to use. When they can, participants should be
                 exhorted to avoid exposure to those triggers. The group can be helpful here in
                 brainstorming ways of avoiding such exposure.

                 Say In Your Own Words:

                 Review with the participants their Self-Monitoring Form (Module 23). It
                 may be useful to make a list of common triggers as well as personal triggers
                 for given individuals. The emphasis is: (1) This is a list of my high-risk
                 situations and (2) These are my personal triggers.

                 In the second part of the group session the emphasis is upon brainstorming
                 ways to avoid high-risk situations. Everyone has needs. However, exposing
                 oneself to triggers that can threaten sobriety and all of the negative
                 consequences associated with using again is very dangerous.

                 What we need to figure out is how to avoid exposure to triggers and at the
                 same time find ways to meet our needs in other ways.

                       Explain ACE Handout.

                       Again it is useful to write down alternative pro-social responses that
                       could be chosen instead of exposure to triggers.




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             Module 24 Handout: ACE

             There are 3 main ways to handle triggers:
             A- Avoid them to begin with. This is often the simplest and safest solution.
             C- Cope with being triggered. This can be difficult to do but it is not impossible. We will
             discuss this ore in our next session.
             E- Escape from what is triggering you. This is a good option when a trigger catches you by
             surprise and there is a safe/ easy way to leave the situation.




             Fill in the table below with some common personal triggers that you have.

                 Trigger                  Ways to Avoid             Way to Escape




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                                          Module 24 Main Points


      You can Avoid triggers, Cope with being triggered or Escape from triggers- ACE

      Avoiding triggers should usually be your first option because it is often the easiest and most solid way to
      not be triggered.

      In order to avoid triggers, you must first identify what triggers you.




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                                                 MODULE 25
                                       Control of Cravings and Urges

               Objectives: 1. To teach participants coping skills when craving can not be avoided.
                2. To exhort participants to use these coping skills in high-risk situations.


                 Content: This session deals with identifying and defining potential coping skills
                 to be used when participants can’t avoid triggers and they therefore experience
                 craving and urges.

                 Say In Your Own Words:

                 Sometimes triggers and therefore cravings cannot be avoided, and it is necessary
                 to find ways of coping with craving and the urges to use that go with it.

                 The most important point to remember is that craving is time limited. If you
                 don’t act upon the urge it will eventually go away. In other words it will pass. I
                 want to define for you a number of coping skills that you can use at that moment.



                            Write on flip chart, blackboard, or overhead:

                 1. Distraction: Reading, a hobby, and exercising are good examples of
                 distracting activities. Once your mind becomes occupied with something else,
                 you’ll find that the urges will go away.

                 2. Talk it through: Another way of coping is talking the craving through
                 with someone else. Talking about craving and urges can pinpoint the source of
                 the craving. Talking about craving also often discharges and relieves the feelings
                 associated with craving.

                 3. Urge surfing: Many people try to cope with their urges by gritting their teeth
                 and toughening it out. But, some urges to certain triggers are hard to
                 ignore. When this happens, you can stay with the urge until it passes. This is
                 called urge surfing




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                 4. Challenge and change your thoughts: When experiencing craving, many
                 people have a tendency to only remember the positive effects and to forget the
                 negative effects of using drugs or alcohol. It is important when
                 experiencing urges to remind yourself of the benefits of not using and the
                 negative consequences of using.

                 5. Self-Talk Coping Skills: You can use an urge as a signal to give yourself a
                 “pep talk,” reminding yourself that you can cope, that you have a plan to deal
                 with these feelings, and that you have many personal and social
                 resources that you can use at this time.


                 After or during the definition of these coping skills, participants should be
                 encouraged to brainstorm other tactics within the categories; that is, other
                 distracting activities, other people to talk things through with, other
                 challenging thoughts to “stinking thinking,” and other things that they could say to
                 themselves to improve their pep talk. They will have an opportunity to practice
                 “urge surfing” in the experiential session.




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                                          Module 25 Main Points


      Cravings are time limited.

      When you can’t avoid or escape a trigger, you have to cope.

      Some good ways to cope include:

          o Distraction: Reading, a hobby, and exercising are good examples of distracting activities. Once
             your mind becomes occupied with something else, you’ll find that the urges will go away.

          o Talk it through: Another way of coping is talking the craving through with someone else.
             Talking about craving and urges can pinpoint the source of the craving. Talking about craving
             also often discharges and relieves the feelings associated with craving.

          o Urge surfing: Many people try to cope with their urges by gritting their teeth and toughening it
             out. But, some urges to certain triggers are hard to ignore. When this happens, you can stay with
             the urge until it passes. This is called urge surfing.

          o Challenge and change your thoughts: When experiencing craving, many people have a
             tendency to only remember the positive effects and to forget the negative effects of using
             drugs or alcohol. It is important when experiencing urges to remind yourself of the benefits
             of not using and the negative consequences of using.

          o Self-Talk Coping Skills: You can use an urge as a signal to give yourself a “pep talk,”
             reminding yourself that you can cope, that you have a plan to deal with these feelings, and that
             you have many personal and social resources that you can use at this time.




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                                                MODULE 26
                                            Anti- Craving Exercises


                 Objectives: 1. To have participants practice the technique of “urge surfing” when
                 experiencing craving. 2. To exhort participants to use urge surfing when experiencing
                 craving, temptations, and urges.


                 Content: This session is designed to have participants imagine experiencing a craving or
                 urge to use, and then to use urge surfing to cope with it.

                 Say In Your Own Words:

                 Urges are a lot like ocean waves. They are small when they start, grow in size,
                 and then break up and dissipate. You can imagine yourself as a surfer who will
                 ride the wave, staying on top of it until it crests, breaks and turns into less
                 powerful, foamy surf.

                 The idea behind urge surfing is similar to the idea behind many martial arts. In
                 judo, one overpowers an opponent by first going with the force of the attack.
                 Urge surfing is similar. You can initially join with the urge as a way of taking
                 control of it. There are three basic steps in urge surfing:


                 1. Take an inventory of how you experience the craving. You focus your
                 attention on your body and notice where you experience craving. For
                 example, Let me see…My craving is in my mouth and nose and in my
                 stomach.




                 2. Focus on one area where you experience the urge. Notice the exact
                 sensations in that area. Is it hot or cold, tingly or numb, tense or relaxed?
                 How big of an area is involved. Notice the sensations and describe them to
                 yourself? Am I experiencing the smell and taste or feeling of alcohol or
                 drugs?




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                 3. Like standing behind a waterfall, just observing the water as it falls
                 down, observe your bodily sensations and your thoughts as they come forth.
                 Don’t criticize them, fight with them, judge them, or anything else. Just observe.
                 Notice how the craving comes and goes. Many people notice that after a few
                 minutes of observing the craving has vanished or that they
                 experience the craving in a new way.



                       The therapist should lead participants through an experiential
                       exercise in urge surfing. Discussion and further practice should
                       follow.




                 Homework:

                       Have participants learn to observe their cravings and urges in a non-
                       judgmental way. The goal is to just observe and to learn what happens
                       to an urge when you do nothing but watch it. The participants can
                       report on what they learn.




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             Module 26 Handout: Urge Surfing Techniques


                 1. Take an inventory of how you experience the craving. You focus your
                 attention on your body and notice where you experience craving. For
                 example, Let me see…My craving is in my mouth and nose and in my
                 stomach.




                 2. Focus on one area where you experience the urge. Notice the exact
                 sensations in that area. Is it hot or cold, tingly or numb, tense or relaxed?
                 How big of an area is involved. Notice the sensations and describe them to
                 yourself? Am I experiencing the smell and taste or feeling of alcohol or
                 drugs?




                 3. Like standing behind a waterfall, just observing the water as it falls
                 down, observe your bodily sensations and your thoughts as they come forth.
                 Don’t criticize them, fight with them, judge them, or anything else. Just observe.
                 Notice how the craving comes and goes. Many people notice that after a few
                 minutes of observing the craving has vanished or that they
                 experience the craving in a new way.




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                                         Module 26 Main Points



      Cravings are time limited.

      Urge surfing can be a good way to cope when you are experiencing an urge.

      Urge surfing is a non- judgmental “going with” the urge rather than fighting it. This is not the same as
      giving into the urge!




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                                               MODULE 27
                                   Managing Thoughts of Your Drug of Choice


                Objectives: 1. To help participants understand the importance of their state of mind in
              maintaining their abstinence from drugs and alcohol. 2. To help participants understand the
              kinds of situations that can lead them to have thoughts about resuming the use of substances.


                 Content: This session deals with the kinds of thought patterns that can lead to
                 a relapse to using drugs and alcohol.

                 Say In Your Own Words:

                 The following are some common situations in which participants may have
                 thoughts about resuming using:

                            Write on flip chart, blackboard, or transparency:

                       Nostalgia: There will be times when you remember the good old days as if
                       using were a long lost friend or where using only had positive consequences.

                       Testing Control: Alcoholics in particular have the tendency to become
                       overconfident about their control over alcohol. They bet that they can
                       have a couple of drinks without harmful consequence. They reason that
                       they can easily stop again tomorrow.

                       Escape: Individuals want to avoid the discomfort associated with
                       unpleasant situations, conflicts, and memories. They just want to get
                       away from it all. It is not a high that is sought but rather numbness from
                       the problems and an inner sense of peace.

                       Relaxation: Thoughts of wanting to unwind are normal. Doing a relaxing
                       activity takes time and effort. The temptation for immediate relief through
                       the use of substances can be strong.

                       Socialization: Many individuals are shy and uncomfortable in social situations, and
                        may “feel” the need for social lubrication in order to feel more at ease and to deal with
                       their inhibitions.

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                       Improved Self-Image: Those people with low self-esteem feel unhappy
                       with themselves when they are feeling inferior to others, when they
                       believe that they are lacking in certain qualities, when they feel
                       unattractive and deficient, and they begin to think about substances as a
                       way to achieve relief.

                       Romance: When people are bored with their lives, they yearn for
                       excitement and romance. They often associate the use of substances to these
                       feelings and begin thinking about using.

                       To Hell With It: Some individuals get to a point in which they lose all
                       incentive to pursue worthwhile goals. Their thoughts express disillusionment;
                       nothing really matters. There is no reason to try. This attitude makes one very
                       vulnerable to a relapse.

                       Crisis: During stress or a crisis, the person thinks that they need to use
                       substances in order to cope. They believe that they just need to use until
                       they get through the crisis and then they’ll stop again.


                            Participants will help the therapist identify other situations in which
                            they experience an increase in “stinking thinking.”


                 As the therapist identifies the situations that will increase thoughts about
                 using, s/he can ask the participants, “What is the problem with this type of
                 thinking, in this situation?”




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             Module 27 Handout: Dangerous Thought Patterns


                 Nostalgia: There will be times when you remember the good old days as if
                 using were a long lost friend or where using only had positive consequences.

                Testing Control: Alcoholics in particular have the tendency to become
                overconfident about their control over alcohol. They bet that they can have a
                couple of drinks without harmful consequence. They reason that they can easily
                stop again tomorrow.

                Escape: Individuals want to avoid the discomfort associated with
                unpleasant situations, conflicts, and memories. They just want to get away
                from it all. It is not a high that is sought but rather numbness from the
                problems and an inner sense of peace.

                 Relaxation: Thoughts of wanting to unwind are normal. Doing a relaxing
                 activity takes time and effort. The temptation for immediate relief through
                 the use of substances can be strong.

                 Socialization: Many individuals are shy and uncomfortable in social situations, and
                  may “feel” the need for social lubrication in order to feel more at ease and to deal with their
                 inhibitions.

                  Improved Self-Image: Those people with low self esteem feel unhappy with themselves when
                 they are feeling inferior to others, when they believe that they are lacking in certain qualities,
                 when they feel unattractive and deficient and they begin to think about substances as a way to
                 achieve relief.

                 Romance: When people are bored with their lives, they yearn for excitement and
                 romance. They often associate the use of substances to these feelings and begin thinking about
                 using.

                  To Hell With It: Some individuals get to a point in which they lose all incentive
                 to pursue worthwhile goals. Their thoughts express disillusionment; nothing really
                 matters. There is no reason to try. This attitude makes one very vulnerable to a relapse.
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                  Crisis: During stress or a crisis, the person thinks that they need to use substances in
                  order to cope. They believe that they just need to use until they get through the crisis and then
                 they’ll stop again.



             Module 27 Handout: Dangerous Thought Patterns



                 The last time that you relapsed which of these thought patterns did you have?




                 Did you “play the movie thought to the end”? That is, did you look past the instant
                 relief to the consequences that would follow later on?




                 What self-talk can you use to challenge these thoughts?




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                                         Module 27 Main Points


      There are some ways of thinking that greatly increase the chance of relapse.

      It is important that you recognize and challenge these thought patterns when they occur.

      When you are thinking about using, play the movie all the way through to the end. Don’t stop at the
      “good part” when you’re high. Keep on going all the way through to the end that you have already
      experienced at least one. Play it all the way through until you are once again sitting in a cell and
      wearing orange.




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                                                 MODULE 28
                                       Practicing Self Talk and Coping Thoughts


               Objectives: 1.To have participants practice using self-talk and other coping skills to
                triggers to use. 2. To have participants think coping thoughts when exposed to triggers.
                3. To have participants practice the effective ways of coping with craving and
                urges.


                 Content: This unit is designed to “inoculate” participants against their craving
                 triggers. Participants are exposed to simulated triggers and practice using self-
                 talk and other coping skills in that situation. Participants practice an appropriate
                 anger response in that situation.

                 Say In Your Own Words:

                            Hand out the COPING WITH URGES self-statement form. This form
                            has been modified to deal with craving and urges instead of
                            anger. Participants can be instructed that these are some of the things
                            that people who effectively manage their craving say to themselves
                            when encountering provocative situations. There are four phases to
                            inoculating themselves from acting impulsively to craving and
                            urges: (1) Preparation for the encounter; (2) Encountering the
                            situation; (3) Dealing with feelings of being overwhelmed; and (4)
                            Talking to yourself after the situation is over.

                 Have participants take a high-risk situation from their list of personal
                 triggers. Ask them to think about the following: What do I have to do
                 and say to myself in preparing to encounter this situation in an effective
                 way? What do I have to do and say to myself when encountering the
                 situation in order to remain calm and to be effective? If by chance
                 craving starts to build, what do I have to do and say to myself in order
                 to remain in control of myself? What do I need to do and say to myself
                 after the encounter is over? Participants should be exhorted to use all of their
                 coping skills including urge surfing, stress management, and self talk skills.




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                            Take a general craving arousal situation and have the
                            participants imagine it while going through the stress inoculation
                            procedure. Include both self-talk and other coping skills in the
                            situation.



                            This is an excellent opportunity to do some role play. Create some
                            fake drugs by crushing up peppermint LiveSavers and putting in
                            small bag, wrapping a paper that says “BEER” around a plastic
                            soda bottle, etc. These do not have to look real to be effective. Have
                            group members role play friends, family and old acquaintances
                            offering/ pressuring the inmate to use. **MAKE SURE TO
                            INFORM THE DW AND UNIT SECURITY THAT YOU ARE
                            DOING THIS AND OF THE PURPOSE OF THIS EXERCISE**



                            The group can brainstorm self-talk and coping skills for each other in
                            their attempts to cope with craving.




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             Module 28 Handout: Coping With Urges-Self Statements



                 Preparing for the Exposure

                 What is going to happen when I... ..?

                 Self-talk strategies (Script #1):

                       1)        This is going to tempt me, but I know how to deal with it.

                       2)        Remember to list all of my coping tactics.

                       3)        The urges will come but I’ll be okay, I know how to cope.

                       4)        Relax-take a deep breath.

                       5)        Easy does it. Remember to keep my sense of humor.


                 Coping When Cravings Start to Build


                 Self-talk strategies (Script #2):

                 1)    It’s time to relax and slow down.

                 2)    My craving is a signal of what I need to do. Breathe...

                 3)    If I feel it, I can do some “urge surfing.”

                 4)    Watch out now for some “stinking thinking.”

                 5)    One will lead to another so I can’t let myself do it.

                 6)    Some people would like to see me go off of the wagon for their own gain.
                       But, I’m going to disappoint them this time. I can cope.




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             Module 28 Handout: Coping With Urges-Self Statements



                 Coping When Craving Feelings Start to Overwhelm

                 You can feel the craving in your body and your thoughts begin to turn to using.

                 Self talk strategies (Script #3):

                 1)    As long as I keep my cool and use my coping skills, I’m in control.

                 2)    Think of what I want to get out of this. What is my long-term goal.

                 3)    I don’t need to prove myself or test my will power.

                 4)    Remember that this urge will pass quickly, if I do nothing. Remember to breathe
                       and relax.

                 5)    Do the urge surfing now. If it doesn’t work, I can leave the situation.

                 6)    Look for the positive. Don’t assume the worst or jump to conclusions.


                 Coping When It’s All Over


                 Self talk strategies (Script #4)

                 1    These are tempting situations and it will take time for the craving and urges not to
                      come.

                 2 Each time I cope, I get stronger.

                 3 That wasn’t as hard as I thought.

                 4 I’m doing better at this all the time!

                 5 I can be pleased with the progress I’m making.




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                 Adapted from Novaco (1975)




                 Module 28 Handout: Coping With Cravings and Urges


                 Reminder Sheet

                 •    Urges are common in the recovery process. They are not a sign of failure. Instead,
                      try to learn from them about what you’re craving.
                 •    Urges are like ocean waves. They get stronger only to a point, then they start to go
                      away.
                 •    You win every time you defeat an urge by not using. Urges only get stronger if you
                      give in and feed them. An urge will eventually weaken and die if you do not feed it.

                 Practice Exercises

                 For next week, make a daily record of urges to use drugs or drink, the intensity of those
                 urges, and the coping behaviors you used.

                 1.     Fill out the DAILY RECORD OF URGES TO DRINK
                        a.     Date
                        b.     Situation: Include anything about the situation or your thoughts or feelings
                               that seemed to trigger the urge to drink.
                        c.     Intensity of urge or craving: Rate your urge, where 1 = none at
                               all, 100 = worst ever.
                               d. Coping behavior. Use this column to note how you attempted to cope with the urge to
                                drink. If it seems like it would help, note the effectiveness of your coping.




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                 Module 28 Handout: Coping with Cravings and Urges Form

   DAILY RECORD OF URGES TO USE DRUGS OR ALCOHOL

    Date           Situation (include your thoughts    Intensity of Cravings (1-100)   Coping Behaviors Used
                   &feelings)
    5/16/98        Was feeling stressed and worried.        75                         Took a shower. Listened to
                   Had bad phone call home.                                            relaxing music.




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                                           Module 28 Main Points



      Urges are a common part of recovery and do not mean failure.

      Every time that you get past an urge or craving without using is a victory!

      There are four phases to coping with urges:

          o Preparation for the encounter

          o Encountering the situation

          o Dealing with feelings of being overwhelmed

          o Talking to yourself after the situation is over




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                                              MODULE 29
                                    What is Relapse Prevention?



             The next modules are from, Relapse Prevention: Review of Practical Skills, a group treatment
             manual developed for the Florida Department of Corrections residential programs for offenders
             with co-occurring mental health and substance abuse disorders. This manual reviews the
             Relapse Prevention Model and focuses on helping participants review and rehearse relevant
             cognitive and behavioral coping skills.
             This manual reviews and rehearses cognitive and behavioral relapse prevention skills
             that offer positive ways of coping with stressful situations as replacements for
             previously learned maladaptive patterns, such as substance abuse and criminal
             behavior. One of the key concepts that this manual focuses on is that mental illness,
             substance abuse, and criminal behavior are related, and that if a participant relapses in
             any of these three areas, they are much more likely to eventually relapse in the other
             two areas as well.
             After reviewing the overall Relapse Prevention Model, this manual focuses on
             specific skills and concepts that make up different parts of the model, including
             lifestyle balance, coping with stress, and meditation. Next, the manual focuses on
             identifying high-risk situations for relapse, relapse set-ups, and seemingly irrelevant
             decisions. A number of sessions review self-monitoring of early warning signs of
             relapse into substance abuse, mental illness symptoms, or criminal behavior. Further
             sessions help participants make specific plans to prevent relapse in any of these three
             areas when they detect such early warning signs. Identifying and managing
             relapse triggers, cravings, and urges is covered next. The Abstinence Violation Effect
             is further reviewed, and participants are helped to develop an emergency plan to keep a
             lapse from becoming a full-blown relapse. Finally, in the last session, participants are
             guided through the process of developing a recovery network.




             OBJECTIVES: 1. To review the relapse prevention model and give an overview of this module.
             2. To help participants understand how the relapse prevention model will benefit them as a
             roadmap to recovery. 3. To increase participants’ commitment and motivation to learning this
             module’s material.



            CONTENT: This session provides an overview of the relapse prevention model


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             Say In Your Own Words:

             Today we are going to start a new section of groups on the topic of Relapse
             Prevention. We are going to review the relapse prevention model and why
             learning about it will help you in your recovery. Today’s session will also help you
             understand how the relapse prevention model is your roadmap to
             recovery. First of all, what do people here remember about the relapse
             prevention model?

                            Solicit responses and encourage them.

             Now let’s review the model. First of all, let’s review what relapse is. Relapse
             means falling back into old unhealthy habits of thinking and behavior. So the
             relapse prevention model is our roadmap to recovery, by teaching us how not
             to relapse.

             For people in this program, there are 3 main kinds of relapse that can happen. Does
             anyone know what these are?

             So the three kinds of relapse that we need to prevent from happening are:

             1) Substance Abuse
             2) Criminal Behavior
             3) Mental Illness Symptoms becoming unmanageable


                              Refer to handout “Relapse Prevention Model Overview”

             Let’s talk about how these three areas are related. If you relapse in one of these
             areas, that can make you more likely to relapse in all three. For example, if you start
             drugging again, you have automatically relapsed into criminal behavior just by
             possession of the illegal substance.

             If someone gets back into their addictive lifestyle, they are more likely to
             commit crimes to support their addiction. Also, substance abuse almost always
             makes mental illness worse, such as depression, anxiety, seeing things that aren’t
             there,    paranoia,     hearing  voices,    mistakes      in   thinking,     poor
             decisions, impulsivity, etc.

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                            Solicit examples from the group about how their substance abuse
                            contributed to the other two types of relapse in their own lives.

             Sometimes mental illness can contribute to people relapsing in the other two areas. For
             instance, if you stopped taking medication for your mental illness, or stopped going to
             mental health counseling, then you would be more likely to have worsening mental
             illness symptoms.

             Once your mental illness symptoms are back, then you are more likely to
             make mistakes in your thinking and behavior, which can cause you to relapse into
             substance abuse or criminal behavior.

             Also, people sometimes try to medicate their mental illness symptoms with alcohol or
             drugs of abuse. These may make your symptoms feel better for a very short time, but
             almost immediately, drugs or alcohol are going to make your mental illness symptoms
             worse.

             The more you use, the worse your mental illness symptoms get, and the more you feel
             like you need to use. This creates a downward spiral, and once again people are likely
             to commit crimes to support their addiction.



                            Solicit examples from the group about how their mental illness contributed
                            to the other two types of relapse in their own lives.



             Relapse into criminal thinking and behavior can also lead to relapse in the other two
             areas. Once you start hanging out with crime associates, you are more likely to be
             exposed to drugs and relapse into substance abuse.

             Also, when you get money from a crime, then you may feel urges to spend it on drugs
             or alcohol, like you might have in the past. Substance abuse will make your mental
             illness worse. Also, the stress that you put yourself under when you commit crimes
             will make you more likely to relapse into mental illness and substance abuse.

                            Solicit examples from the group about how their criminal behavior
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                            contributed to the other two types of relapse in their own lives.

                            Have group members write down ways that one of the three areas has made
                            the other two worse in the blank on the handout.




             So we can see that these three areas are connected, and the only way to
             prevent relapse is to learn new skills that will help you prevent relapse in all
             three of these areas. That’s where the relapse prevention model comes in.

             One of the most important ideas to remember in the relapse prevention model is that of
             lifestyle balance. For instance, we just saw that relapsing in any one of these three areas
             can cause our lifestyle to get out of balance and quickly cause us to relapse in the other
             two areas as well.

             We need to balance the different needs, wants, and shoulds in our lives. If we
             only do things that we feel like we should be doing, then we may feel deprived
             of enjoyable activities and wants, and be more likely to relapse into substance
             abuse.

             We also need to replace our old substance abuse habit with other healthy addictions like exercise
             or meditation. This will help keep us from getting too stressed out as well, like when we work
             all the time and then get so stressed and feel deprived that we relapse. In a later group we will
             focus more on lifestyle balance, and developing a lifestyle balance plan.

             To prevent relapse, we need to learn to keep our mental health, addiction, and criminal
             thinking from getting out of control. One way we do this is through learning how to
             deal with life and the things that stress us out by coping successfully with the different
             parts of our lives.

             We will be learning new skills in later groups to help us cope with stress, deal with our
             negative emotions, change our thinking, deal with other people in a good way, learn
             how to ask for and get help, and make good choices about finances, jobs, and housing.

             Another important part of relapse prevention is the Abstinence Violation Effect.
             Can anyone guess what it is?

                     Solicit answers, and then go on to describe.

             So the Abstinence Violation Effect (A.V.E.) is a wrong belief, that if we make
             one mistake, then we have screwed up completely. So if we have a slip, or a
             lapse, and use drugs or alcohol one time, if we believe in the Abstinence
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             Violation Effect, we will think we have completely blown our recovery from
             drugs and alcohol, and that we will automatically go back to a full blown relapse.
             This belief is not true!




             If we quickly realize our mistake, and put into action our emergency plan to cope
             with a lapse, then we can get right back to recovery and abstinence, and prevent a
             full-blown relapse to our addiction. We will develop plans to cope with a lapse more
             in a later group.

             The same is true of criminal behavior. For example, if we have one slip and we commit
             a petty crime, then that does not mean that we automatically have to relapse to a full-
             blown criminal lifestyle; we can stop our criminal behavior and get back on track with
             abstaining from criminal behavior.

             The same is also true of mental illness; suppose one day we miss our depression medication,
             or our counseling, and our depression gets worse that day. That does not mean that we
             automatically are going to relapse to fullblown depression; instead, we get ourselves back on
             track with our mental health medication and counseling as quickly as we can.

             So the A.V.E. means that we have to learn ahead of time that if we have a
             lapse, we don’t have to feel totally guilty and angry at ourselves, because that will only
             contribute to a full blown relapse. Instead, we remember that a lapse is simply a
             mistake, and that we can quickly stop it from becoming a full-blown relapse by getting
             help and putting our emergency plan into action, and then learning from our mistake.

             The A.V.E. does not mean that we are suggesting that engaging in substance abuse,
             criminal behavior, or neglecting your mental health needs are safe
             activities with no consequences. On the contrary, these are dangerous, highrisk
             behaviors that could lead to a full blown relapse. The best way to prevent a relapse is
             not to lapse at all.

             We are all human, and all of us make mistakes at one time or another. The reason to
             learn about the A.V.E. is not to give ourselves permission, or an excuse, to lapse or
             relapse.

             The reason we learn about the A.V.E. is because we are human, and therefore we make
             mistakes. Learning about the A.V.E. helps us be prepared and plan how to cope with a
             mistake in a positive way that gets us back on track as soon as possible. We will spend
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             more time on the A.V.E. in a later group.




             Another part of the relapse prevention model is identifying our high-risk
             situations, as well as triggers, which could contribute to our relapsing. Then
             we can plan on how to avoid those high-risk situations when we can, and how
             to cope with them successfully when we can’t avoid them. We will also learn
             more about how to cope with and manage cravings and urges to relapse.

             We will also learn how to monitor ourselves to identify our early warning
             signs that tell us we might be headed for relapse if we don’t change some
             things. That way we can head them off at the pass, and prevent a relapse.

             We will also review Setups to Relapse, and Seemingly Irrelevant Decisions,
             which is when we put ourselves in high risk situations without noticing or
             admitting to ourselves that we are trying to give ourselves an excuse to
             relapse. An example of this could be trying to make ourselves believe that
             going back around our drug or crime associates in the old neighborhood is not risky,
             when it really is.

             We will identify our roadblocks to recovery, and we will focus on developing specific
             relapse prevention and recovery plans, and will learn how to develop a recovery
             network. All of these are part of the relapse prevention model. Today’s group was to
             help you get an idea of the big picture, and how all the pieces of the relapse prevention
             model fit together.

             Today we looked at an overview of why it is important to learn the things we will be
             learning over the next section of groups, and how they are all part of the relapse
             prevention model.




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                 Module 29 Handout: Relapse Prevention Model Overview

             The Three Main Areas which need to be addressed to prevent relapse:

             • Substance Abuse
             • Criminal Behavior
             • Mental Illness

             These three are all connected; relapse in one area can contribute to relapse in all three areas.

             How did my behavior in one of these three areas contribute to making the other two areas
             worse?____________________________________________________________


             Lifestyle Balance- keeping our shoulds, wants, and needs, and the different areas of our life in
             balance.

             Coping with Life and Sources of Stress Successfully
                   • Healthy Addictions - exercise, meditation, etc.
                   • Dealing with Negative Emotions
                   • Changing our Thinking
                   • Positive Communication
                   • Asking For Help
                   • Dealing with Social Pressure
                   • Dealing with Conflict
                   • Finances/Employment choices
                   • Housing choices

             Abstinence Violation Effect - If we believe that one lapse will automatically lead to a full-blown
             relapse, then it most likely will. If we change this belief, we can keep a lapse from becoming a
             relapse.

             High Risk Situations and Triggers to Relapse: Identifying, Avoiding, and Coping with them

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             Cravings and Urges Coping with and managing them.

             Self-Monitoring for early warning signs of relapse

            Seemingly Irrelevant Decisions

             Developing a Recovery Network and a Recovery Plan

             Identifying our Roadblocks to Recovery




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                                         Module 29 Main Points



      Having a solid relapse prevention plan will increase your chances of success.

      Your plan needs to address substance sue, mental health and criminal behavior because all three are
      inter-connected.

      Relapse in one area can lead to relapse in another area.

      Seemingly Irrelevant Decisions (SIDS) can lead us to relapse.

      The Abstinence Volitional Effect (AVE) is when we let one mistake (lapse) turn into a full blown
      relapse.




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                                                  MODULE 30
                                                Lifestyle Balance


            OBJECTIVES: 1. To review the importance of lifestyle balance in relapse prevention. 2. To help
            participants identify and prioritize areas of life for balance. 3. To apply the concept of lifestyle
            balance in planning for their own life at present and post-release.

             CONTENT: The content of this session focuses on lifestyle balance as an important
             overall model for relapse prevention and maintaining recovery from substance abuse,
             mental illness, and criminal behavior.

             Say In Your Own Words:

             Today we are going to review lifestyle balance as an important overall model for
             how to maintain our recovery from substance abuse, mental illness, and criminal
             behavior. What often happens when people become stressed is that they stop
             practicing their important coping behaviors, and before they know it they are headed
             for relapse.

             For instance, people have a lot of stress from having to do a lot of things in a short time
             at work, and then they stop exercising, stop meditating, stop going to counseling
             sessions, or stop going to 12-step meetings. They may do this thinking that they will be
             able to get more done if they just work. But if they neglect these important self-renewal
             activities, then they begin to feel “burned out” and resentful of the demands on their
             time.

             If the level of “shoulds” in their life reaches too high a level and outweighs the level of
             “wants”, then they are likely to desire indulgence, and want to take a “break”, which can
             lead to relapse into impulsive behavior such as substance abuse, or criminal behavior.

             The basic idea of lifestyle balance is to maintain the level of ‘wants’ and positive self-renewal
             activities to keep it in balance with the level of ‘shoulds’ in your life, so that you feel content,
             instead of feeling deprived, resentful which can lead to cravings for indulgence and wanting to
             escape.

             Paradoxically, when people react to stress by dropping these important coping behaviors
             or other positive leisure activities, they end up being less productive at work and more
             likely to relapse. Remember that too much stress is a sign of lifestyle imbalance, and
             may mean making decisions to keep things in balance (for example, choosing a job
             that is not too demanding or too boring).

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                    WRITE ON THE BOARD (If available):

                    “HOW AND WHY HAS YOUR LIFESTYLE GOTTEN OUT OF BALANCE IN THE
                    PAST?”

             Now let’s come up with a list of ways that your lives have gotten out of balance in the past. What
             are some specific examples of how this continued the cycle of addiction, criminal behavior, and
             contributed to mental illness symptoms?

                    Write their examples on the board, or have them write their own down in
                    their notebooks.

             Now let’s come up with a list of different areas of our lives that need to be
             balanced.



                     Write their examples on the board, or have them write them down in their
                 notebooks. Once they have generated a list, pass out the handout “Dimensions of
                 Lifestyle Balance for Recovery” and review first page with them.


             Since we cannot focus on all these areas of life at once, people need to decide which
             areas they want to focus on most, and which are most important immediately after
             discharge. How will you try to balance these competing demands.

             At first you may need to focus on how to survive (such as basic physical/financial needs) without
             relapsing into substance abuse, criminal behavior, or mental illness. First focus on this in your
             writing for the present, and then move on to how you would like their life to be balanced in these
             areas when you are released.




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                 Module 30 Handout: Dimensions of Lifestyle Balance for Recovery



             On the next two pages are lifestyle dimensions that need to be balanced in order to
             maintain recovery from substance abuse, mental illness, and criminal behavior. In
             parentheses are examples of some needs or activities that need to be taken care of in
             order to maintain balance in these areas.

             Lifestyle balance is not an end state; maintaining balance is an ongoing process
             which takes time, thoughtful planning, effort and help from others. As your
             circumstances change, the right balance for you will most likely change somewhat,
             and balance is going to be different for different people depending on their likes,
             dislikes, abilities, and circumstances.

             Certain things are crucial (‘shoulds’, such as maintaining conditions of release or
             parole), others are more subject to your preferences (‘wants’), such as what kinds of
             positive self-renewal exercises are most enjoyable and uplifting for you. Some things
             may be both shoulds and wants.

             You may need to do certain things daily (such as meditation, prayer, 12-step
             groups) and other things only three times a week (maybe exercise), while others
             are only done as scheduled (parole officer visits). You will need to keep thinking
             about how to maintain balance and trying out different things until you find what
             works for you; this is a lifelong learning process, which is made up of many small
             steps.

             Remember to try to balance shoulds and wants as much as possible so that you
             don’t feel deprived, resentful, and stressed out. If shoulds are too high and wants too
             low, this can lead to a desire for indulgence and escape, impulsive, self-
             destructive behavior, and relapse into substance abuse, mental illness symptoms,
             and/or criminal behavior!
                                                     Activities:

             • Think about how you will balance these competing demands, and write that in
               the space below.

             • Fill out the next page on the best ways to balance your life now.

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             • Fill out the third page as you would like to have your life balanced shortly after
                 release. At first after post-release, you may need to focus on how to survive
                 (basic physical/financial needs) without relapsing into substance abuse, criminal
                 behavior, or mental illness.



                 Module 30 Handout: Dimensions of Lifestyle Balance for Recovery

                                  HOW I WANT TO BALANCE MY LIFE NOW




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                                         Priority
              Lifestyle Dimension        Rate 1-5   “Wants”     “Shoulds” (Musts)




              Basic Survival
              food, shelter, etc


              Substance Abuse
              Recovery 12steps,
              counseling, support
              groups, etc.

              Mental Illness Recovery
              therapy sessions,
              prescribed medications,
              etc.


              Legal Recovery
              parole, probation,
              outstanding courts
              cases, custody, etc.


              Emotional / Social
              family, friends, support
              systems, etc.


              Financial/ Employment
              education, training,
              obtaining job, resume,
              etc.



              Positive Self Renewal
              exercise, meditation,
              church, etc.



              Leisure/ Recreation
              sports, hobbies, self-
              growth, reading, etc.



              Other




                  Module 30 Handout: Dimensions of Lifestyle Balance for Recovery


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                          HOW I WANT TO BALANCE MY LIFE SHORTLY AFTER RELEASE


                                         Priority
              Lifestyle Dimension        Rate 1-5   “Wants”          “Shoulds” (Musts)




              Basic Survival
              food, shelter, etc


              Substance Abuse
              Recovery 12steps,
              counseling, support
              groups, etc.

              Mental Illness Recovery
              therapy sessions,
              prescribed medications,
              etc.


              Legal Recovery
              parole, probation,
              outstanding courts
              cases, custody, etc.


              Emotional / Social
              family, friends, support
              systems, etc.


              Financial/ Employment
              education, training,
              obtaining job, resume,
              etc.



              Positive Self Renewal
              exercise, meditation,
              church, etc.



              Leisure/ Recreation
              sports, hobbies, self-
              growth, reading, etc.



              Other



                                             Module 30 Main Points

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      Life consists of things that we should/must do and things that we want to do.

      A healthy recovery is a balanced recovery.

      Try to keep a balance between wants and shoulds.

      Wants can be used as a way to reward yourself for fulfilling your shoulds.

      Areas of life to keep in balance:

          o Basic Survival

          o Substance Abuse Recovery

          o Mental Health Recovery

          o Legal Recovery

          o Social/ Emotional Relationships

          o Finances and Employment

          o Positive Self-development

          o Leisure Activities




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                                                MODULE 31
                                              Coping with Stress
               OBJECTIVES: 1. To help participants become aware of healthy ways to cope with stress
              and unpleasant emotions. 2. To help participants assess what areas they need to develop
              coping skills in, and develop a specific Stress Buster Action Plan to address five of these areas.

             CONTENT: This session reviews reasons why drug and alcohol use are not effective
             ways of dealing with stress and unpleasant emotions. Healthy ways to cope with stress
             and unpleasant emotions are reviewed, and participants self-assess in what areas they
             need to develop coping skills. Participants are asked to develop a specific Stress
             Buster Action Plan to address five of these areas, and discuss how they will put it into
             practice, as well as potential obstacles.

             Say In Your Own Words:

             Everyone has stress in their lives. Stress is something in our lives that causes us to
             feel anxious, nervous or afraid. Stress can also contribute to us having other
             unpleasant feelings. Many people who have become addicted to drugs or alcohol
             have learned to try to cope with stress by numbing their anxiety or other unpleasant
             emotions with the drugs or alcohol.

             Numbing unpleasant feelings with drugs or alcohol may work for a little while, but over
             time it is not a good coping strategy to deal with stress. What are some of the problems with
             using drugs and alcohol to numb unpleasant feelings?

             Solicit and encourage answers, and then go on to describe.

             So, there are a number of different problems with trying to cope with stress by
             numbing unpleasant feelings with drugs or alcohol. Here is a list of problems with
             this coping strategy:

                 1. Tolerance develops to the drug, and so each time requires more to get the
                    same effect. This leads to addiction.

                 2. After the drugs wear off, the unpleasant feelings are still there, but they
                    often get stronger over time the longer they are avoided. We haven’t
                    learned better ways to cope.

                 3. Drugs and alcohol do not actually do anything to solve any problems in our
                    lives, so while we get high and avoid our problems, the problems pile up
                    and get worse.

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                 4. Unpleasant feelings are often related to problems in our lives, and when we
                    numb these feelings with drugs or alcohol, we cut off an important source
                    of information about what problems we need to deal with.

                 5. Drug and alcohol use keep us from being able to make good decisions and
                    also keep us from being in control of our behavior. Using drugs or alcohol
                    can also lead to criminal behavior or behavior that puts us at risk for self-
                    harm, including risky sexual behavior that can lead to AIDS and other
                    diseases. Drugs and alcohol also damage our bodies and brains.

                 6. Drug and alcohol use can also make our mental illness symptoms worse.



             In today’s group, we are going to look at some different ways to cope with stress and
             the unpleasant feelings that are related to stress. People in recovery need to develop
             new and better coping skills to replace their substance abuse. This is also true because
             when stress is not dealt with effectively, it can also lead to mental illness symptoms
             getting worse. Stress can also make people act without thinking and make bad
             decisions. Also, remember that unpleasant emotions, which are often associated with
             stress, is one of the Big Three high-risk situations for relapse. So stress can make you
             more vulnerable to relapsing into substance abuse, criminal behavior, and mental
             illness. This is why it is so important to develop effective ways to cope with stress.

             There are a number of different healthy things that people can do to cope well
             with stress and with unpleasant emotions. These fall into several categories.


                    Give out handout “Coping with stress” and review with group; it may be
                    helpful to read it to them, or ask for volunteers to read it aloud.

                    Have participants fill out each part, and share their answers with the
                    group.

                    If individuals get stuck, involve the group in helping them come up ideas.

                    Have the group discuss how they will work toward their goals in their
                    Stress Buster Action plans, a little at a time, over time, so that they will not feel
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                   overwhelmed or stressed out.




                    Help the group discuss possible roadblocks to putting their plans into
                    action.




             In our next group, we will have a chance to practice meditation, one of the most important of
             these stress busters. We will also get a chance to talk about how people are doing with putting
             their plans into action. Between now and next group, try to take at least one step towards
             meeting one of your 5 goals in your Stress Buster Action Plan.




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             Module 31 Handout: Coping with Stress
             Read through the following list of ways to help cope with stress. Write in additional ways that
             you need to cope with stress in the blanks provided. Circle the items that you need the most work
             on in order to cope with your stress and unpleasant emotions effectively. Fill out your Stress
             Buster plan.

             1) Healthy Lifestyle - A healthy body helps us cope with stress and unpleasant emotions
                a) Eating regular, healthy meals.
                b) Getting enough sleep on a regular schedule.
                c) Staying off drugs and alcohol; Avoiding cigarettes, caffeine, fats, sugars.
                d) Practicing safe sex to avoid catching diseases.
                e) Regular doctor’s visits and taking medications as prescribed.
                f) Others_________________________________________________________


             2) Social Support- Talking to others helps us cope with stress/unpleasant emotions
                a) getting help from others
                b) friends, family, and others who are good for us and care about us.
                c) Going to recovery meetings or other support groups.
                d) Church or spiritual groups help many get social support.
                e) Getting help from doctors, therapists or counselors.
                f) Others__________________________________________________________


             3) Life skills - When we learn specific coping skills to deal with the different parts of our life
                well, we feel better and our problems don’t tend to pile up so much because we keep taking
                care of them a little bit at a time. Some of these are skills that we have been learning in this
                program. Some skills will need to be developed after you are done with this program, so it is
                important to keep on learning better ways to deal with life.
                a) Managing our money and paying our bills
                b) Managing our time to get done what we need to
                c) Job skills
                d) Decision -making and making good lifestyle choices
                e) Relapse prevention
                f) Others__________________________________________________________


             4) Meditation - Regular meditation helps us to deal with negative feelings and reduces anxiety.
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                  It also allows us to deal better with stress after we have meditated, and be clearer in our
                  decision-making. It is also a natural and healthy way to “get high”! Prayer also helps many.

             5) Exercise- Regular exercise, at least two or three times per week, helps us cope with stress, is
                a natural antidepressant, and makes our body able to fight off sickness better. It is also a
                natural and healthy way to “get high”!




             Module 31 Handout: Coping with Stress
             My Stress Buster Action Plan: The top five things I need to do to cope with stress
             better.


             Remember these are goals to work toward a little at a time. You may only be able to do
             one new thing at a time. That’s fine; put them in order of which healthy habit or new
             skill you want to develop first, and then second, and so on. These are supposed to help
             you, and are not designed to make you feel more stressed!


             1)




             2)




             3)




             4)




             5)
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                                          Module 31 Main Points



      Stress is a natural part of life.

      How you handle stress will impact your recovery.

      Sometimes people try to use drugs and alcohol as a way to cope with stress. This solution always ends
      up leading to more stress in the long run.

      Some healthy ways to deal with stress are:

          o Leading a healthy lifestyle

          o Using social support systems

          o Developing good life skills

          o Meditation

          o Exercise




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                                                   MODULE 32
                                                    Meditation


               OBJECTIVES: 1. To help participants learn about the benefits of meditation in coping with
               stress and unpleasant feelings. 2. To give participants a guided meditation experience which
               may help motivate them to maintain a daily meditation practice post-release. 3. To give
               participants tips and encouragement to commit to regular meditation practice post- release.

             CONTENT: This session helps participants learn more about the benefits of
             meditation in coping with stress and unpleasant feelings, as well as its other benefits.
             Participants will be guided through a meditation experience, which may help
             motivate them to maintain a daily meditation practice. Participants will be
             encouraged to commit to a daily meditation practice upon discharge, and given tips on how to do
             so.

             Say In Your Own Words:

             In our last group, we reviewed ways to cope with stress effectively. In today’s
             group we will be learning more about one of the most important ways to cope
             with stress effectively, which is meditation. We will be reviewing the benefits
             of meditation, as well as get a chance to practice a meditation exercise.

                    Give out handout “Meditation Exercise”

             Meditation is a natural, refreshing, healthy way to “get high” and temporarily leave life’s
             stressful situations behind. Some of the benefits of meditation are that it reduces anxiety
             and stress, helps decrease other unpleasant emotions, promotes better physical health,
             helps the body fight off diseases and heal, increases clear thinking, creativity, and good
             decision making, helps people with sleep problems get to sleep, and increases mental
             alertness and productive energy.

             Meditation also helps you cope better with life after you are done meditating. It doesn’t
             just help you during meditation; it helps you during the rest of your day as well. That’s
             why it is important to try to meditate at least once a day for at least 15-20 minutes to get
             the benefits. Many of you have already experienced meditation in the daily schedule of
             this program. Part of what we will do in this group is to help you maintain a
             meditation practice even after you leave this program or are no longer required to
             attend group meditation sessions in the program.



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             Now we are going to do a short, guided meditation exercise, which combines many
             of the components of meditation that you have experienced and that make
             meditation a powerful health-enhancing practice. First, everyone should get
             comfortable where you feel that you can relax. Put your handout away where you
             can get it later.

                       People may want to put their chairs against the walls in order to feel more
                     secure and relaxed that no one is behind them, or you may want to have the
                     group in a circle for the same reason. Do what is practical with the size of
                    the group so that people can relax.

                      Make a mental note of what time you start the exercise, since the longest
                    you want it to last is 15 minutes.

                      Dim the lights if possible, and close any doors to keep background noise to
                    a minimum.

                       Read the following script in a calm, slow tone, just loud enough for everyone
                    to hear, and with pauses between sentences.

                      Do the deep breathing with them; the more you are able to relax, the more
                    they will be able to.

                      As you continue through the exercises, let your voice get slower and
                    softer, with longer pauses in between sentences.

                       Watch the participants and modulate your voice in tune with their
                    relaxation responses.

             Sit in an upright, comfortable posture, with your feet flat on the floor, and your hands
             on your knees or in your lap… If you can breathe through your nose during this
             exercise, that is the best way to breathe for meditation, but if you can’t, then it is okay to
             breathe through your mouth…


             Close your eyes, and start by taking a slow deep breath, so that the breath
             goes into first your stomach and then your chest… Let your stomach relax, so that it
             expands as the breath comes in, and then let your chest expand with the breath… Hold
             the breath for a moment, only as long as is comfortable, and then let the breath out slow
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             and long…

             Repeat this deep breathing for six or seven times, and as you breathe, listen to the sound
             of your breath going in and out … As you breathe out, let go of any stress, tension,




             worry, or discomfort, and let it flow out with the breath… As you breathe in, feel fresh,
             rejuvenating energy coming into your body…That’s right…Keep doing this deep
             breathing…

                    Pause for 10 seconds while people are doing their deep breaths; do the deep
                    breaths yourself…

             Now let your breathing return to its natural rhythm, and begin to let all the
             different parts of your body relax… With your eyes closed, see your breath as a warm,
             light color flowing from your lungs into the different parts of your body… from your
             toes all the way up to your head…

             So your breath is flowing into your toes, and your toes are relaxed…
             your breath is flowing into your feet, and your feet are relaxed…
             your breath is flowing into your calves, and your calves are relaxed…

             your breath is flowing into your knees, and your knees are relaxed…
             your breath is flowing into your thighs, and your thighs are relaxed…
             your breath is flowing into your hips, and your hips are relaxed… That’s right…

                    Pause for 5 seconds…

             your breath is flowing into your stomach, and your stomach is relaxed…
             your breath is flowing into your chest, and your chest is relaxed…
             your breath is flowing into your lower back, and your lower back is relaxed…
             your breath is flowing into your shoulders, and your shoulders are relaxed…

             your breath is flowing into your upper arms, and your upper arms are relaxed…
             your breath is flowing into your elbows, and your elbows are relaxed…

             your breath is flowing into your forearms, and your forearms are relaxed… your
             breath is flowing into your hands, and your hands are relaxed…
             your breath is flowing into your fingers, and your fingers are relaxed…
             That’s right…

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                    Pause for 5 seconds…

             your breath is flowing into your neck, and your neck is relaxed…
             your breath is flowing into the back of your head, and the back of your head is relaxed…




             your breath is flowing into the top of your head, and the top of your head is relaxed…
             your breath is flowing into the middle of your head, and the middle of your head is
             relaxed…

             your breath is flowing into your forehead, and your forehead is relaxed… your
             breath is flowing into your eyes, and your eyes are relaxed…
             your breath is flowing into your ears, and your ears are relaxed…

             your breath is flowing into your nose, and your nose is relaxed…
             your breath is flowing into your lips, and your lips are relaxed…
             your breath is flowing into your cheeks, and your cheeks are relaxed…

             your breath is flowing into your jaw, and your jaw is relaxed…
             your breath is flowing into your tongue, and your tongue is relaxed…
             your breath is flowing into your chin, and your chin is relaxed… that’s right…

                    Pause for 5 seconds…

             If there are any parts of your body that are still holding some tightness, keep breathing
             into that part of your body, and letting the tension out with your out-breath… So, now,
             let all of the different parts of your body be fully relaxed and comfortable, and full of
             peace…

                    Pause for 6 seconds…

             Now visualize yourself in a beautiful, peaceful place in nature, a place that you
             may have been, a place where you are safe… and warm… and happy… and at
             peace… this place is somewhere special to you, somewhere that you especially
             like… perhaps you are on top of a mountain… perhaps you are in a forest… perhaps you
             are by the ocean… perhaps you are by a river or lake, with beautiful grassy banks…
             wherever you choose to be, let it be somewhere where you are completely peaceful, safe,
             and relaxed…

                    Pause for 7 seconds…

             Inhale the peaceful atmosphere… and exhale any discomfort… with each inbreath, let
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             the beautiful fresh air flow into your body, rejuvenating and
             refreshing you… and … feel the sun shining on your back, warming your body… let
             each outbreath be a release of whatever you don’t want to hold onto anymore…That’s
             right...




             as a gentle breeze ruffles your clothing… you can smell the scent of the pine trees
             nearby… and smell the flowers… and the sound of a nearby stream gurgles in the
             background…so you are floating in an island of bliss… the place you have always
             been looking for…you are at rest…

                    Pause for 8 seconds…

             Let yourself be in this place and enjoy its beauty and peace… If feelings or thoughts
             arise… watch them go by like clouds floating past in the sky…
             sometimes large… sometimes small… sometimes white and fluffy…
             sometimes dark…but only temporary thoughts or feelings… remember, those thoughts
             and feelings are not who you are… you are the one who watches the thoughts and
             feelings go by… like clouds floating by in the vast blue sky… but you are undisturbed
             by them…perfectly at peace…

             Now we will be meditating for a few more minutes… continue to let yourself be in
             your beautiful spot in nature… and keep breathing in the beautiful peace of that
             place…

                    Watch the group, and let their behavior help you decide when to begin bringing
                    them back out of meditation. If they get restless, then it is time to bring them
                    back.

                    The longest amount of time for the exercise should be around 15 minutes, so no
                    one gets bored or uncomfortable. The more pleasant and easy the experience,
                    the more they will want to meditate on their own.

                    Bring them out of meditation gently and slowly. Let your voice start out slow
                    and soft, and gradually bring it back to a normal speaking tone and rate.


             Gradually and gently bring your awareness back to this room and into your body…

             Feel yourself in your body, with your two feet on the ground, connected to planet

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             earth.

             Now take a deep breath, and let it out slowly, and now another deep breath,
             and let it out slowly. Now take one last deep breath, and let it out slowly.

             As soon as you are ready, open your eyes.

                      Let everyone open their eyes, then stand up and turn on the lights.




             Now stand up and stretch your body a little bit to help wake yourself back up.

                      After everyone has sat back down, ask the group to share what their meditation
                      experience was like, and what they particularly liked about it, and how they felt
                      different from before.

                      Ask if people would like to feel this way on a regular basis and then move to
                      reviewing the handout which gives tips on how to maintain a regular
                      meditation practice.

                       Encourage people to make a commitment to themselves to meditate regularly
                       by signing and dating the handout, just for themselves to keep. Encourage
                      them also to decide on and write down a regular daily meditation time on the
                      sheet for when this program no longer requires them to attend meditation
                      groups.

                      If there is time left over, review Stress Buster Action Handouts from previous
                       group and ask what steps any have taken towards any of their goals.

                      If people have not taken any steps, you can encourage them by pointing out that
                       they just have taken a step to coping with stress in this group by deciding to
                       meditate on a regular basis. You can also help them brainstorm ways to put
                       their plans into practice, and involve the group in helping people overcome their
                       obstacles.




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             Module 32 Handout: Meditation Exercises


             Benefits of Meditation


             Reduces anxiety and stress, helps decrease other unpleasant emotions.


             Promotes better physical health, helps body fight off diseases and heal.


             Increases clear thinking, creativity and good decision-making even after meditation.


             Helps people who have trouble sleeping get to sleep; helps many people need less sleep.


             Helps you cope better with life after you are done meditating.


             Increases mental alertness and productive energy after meditation.


             A natural, refreshing, healthy way to “get high” and temporarily leave life’s stressful situations
             behind.



             At least once a day, and as needed, perform a meditation exercise for at least
             15-20 minutes each time to calm your mind and body. Be sure to meditate in
             a dark and quiet place, if possible. It is helpful to meditate at the same time
             and place each day, because it becomes a regular habit and it makes it easier
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             to meditate each time. Many people like to meditate in the morning, and find
             that they have a calmer attitude and clearer mind throughout the day after
             meditating. Other people like to meditate in the evening, or right before
             bedtime; this can help them fall asleep. Whatever is practical with your daily
             life and works best for you is fine. Sometimes people find that they need to
             meditate extra sessions during the day if they are tired or under a lot of stress.
             Meditating at least once a day increases the benefit. Over time, you can
             gradually meditate for longer periods of time, or more than once a day, to
             increase the benefits of meditation. Below is one example of a meditation
             exercise that includes several different meditation techniques. Use whatever
             meditation techniques work best and are most rejuvenating for you.




             Module 32 Handout: Meditation Exercises


             1) Sit in an upright, comfortable posture, (or lie down if more comfortable, if
             possible on back, or if not on side), close eyes, and start by taking five slow deep
             breaths, so that the breaths go into first your stomach and then your chest, and let
             them out slowly as well. Hold each breath for a moment, only as long as is
             comfortable.

             2) Let your breathing return to its natural rhythm, and begin to let your body relax.

             3) Visualize yourself in a beautiful, peaceful place in nature, and inhale the
             peaceful atmosphere into all the different parts of your body, starting with your
             toes and moving up, and exhale any stress, tension, worry, or discomfort.

             4) Let yourself be in this beautiful place and enjoy its peace. If distracting feelings
             or thoughts arise, watch them go by like clouds in the sky, sometimes intense,
             sometimes mild, but only temporary thoughts or feelings, that are not who you are.

             5) You can also focus on the space between the breath, or the space between two
             thoughts, or look at or think about the sky, to help your mind calm down.

             6) Throughout the day, if you feel yourself becoming stressed, take some deep
             breaths, and remember the calm, peaceful space of your meditation.


             I realize how important meditation is to my recovery, so I am making a
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             commitment to meditate on a daily basis.

             After this program no longer requires me to meditate, my regular daily
             meditation time will be at _____________




             Signature                                                      Date




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                                          Module 32 Main Points



      Meditation is an excellent way to reduce stress.

      Mediation has several benefits, not the least of which is that it’s FREE!

      To receive the most benefit from meditation, practice it regularly and often.




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                                                MODULE 33

                                            High-Risk Situations


             OBJECTIVES: 1. To educate participants about common high-risk situations. 2. To help
            participants identify their own high-risk situations.

             Content: This session educates participants about common high-risk situations for
             relapse and helps them identify their own high-risk situations.

             Say In Your Own Words:

             In previous groups we learned about common high-risk situations for relapse into
             substance abuse. In today’s group, we will review those situations, and identify our
             own high-risk situations.

             First of all, what are the Big Three, the most common high risk situations for relapse
             that we learned about before?

                    Solicit their responses, write on board if possible. Review the Big Three
                    below.

             Feeling Bad (Unpleasant Feelings) - the most common situation for people to
             relapse is when they feel angry, sad, bored, anxious, stressed, embarrassed, or
             guilty.

             Social Pressure - the second most common situation for people to relapse is
             when they are around others who are using. The social pressure can be
             indirect, which is what happens when you are simply around others who are
             using, or the social pressure can be direct, when others offer you a drink or
             drug, and try to encourage you to use it. People might even make fun of you
             for not using.

             Fights - (or interpersonal conflict) the third most common situation for people to
             relapse is after they have been in an argument or have been criticized by
             someone else.

             Other relapse situations that are not quite so common as the Big Three, but that you
             should still be aware of are:

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             Pleasant Feelings - using substances to “celebrate” or try to get more of a good
             feeling.

             Urges and Cravings - having a sudden strong desire to use.

             Testing Personal Control - when people try using to see if they can now
             control their use, or “handle” it this time.

             Feeling Bad Physically - when people try to decrease their physical pain or
             discomfort through using.



                    Go over handout “Identifying High Risk Situations”



             This handout outlines the types of relapse situations in general for you. Now it is your
             turn to identify your specific high risk situations. Next to each category, write as many
             high risk situations as you can. What are your specific high risk situations?

             Keep in mind that when you used, you probably did so in specific places, at certain
             times of the day or week, with certain people, and that you used certain things to get
             high. If you can identify your old patterns of use, then you can know what your own
             high risk situations are likely to be.

                    Have participants fill out sheet, and then ask people to give examples of their 3
                    highest risk situations. Try to generate discussions of what are best ways to
                    avoid and cope with these situations.


             We will be spending more time on coming up with ways to avoid and cope with
             these situations in future groups, so keep this sheet.




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              Module 33 Handout: High-Risk Situations


              The Big Three (the most common relapse situations)

              1) Feeling Bad (Unpleasant Feelings) - the most common situation for people to
              relapse is when they feel angry, sad, bored, anxious, stressed, embarrassed, or
              guilty.

              What are the negative emotions that I tended to avoid the most by using? ___________________



              2) Social Pressure - the second most common situation for people to relapse is
              when they are around others who are using. The social pressure can be
              indirect, which is what happens when you are simply around others who are
              using, or the social pressure can be direct, when others offer you a drink or
              drug, and try to encourage you to use it. People might even make fun of you
              for not using.
              Who did I use to use with, and who would be most likely to pressure me to use? _____________




              3) Fights - (or arguments) the third most common situation for people to
              relapse is after they have been in an argument or have been criticized by
              someone else.

              Who did I use fight or argue with before using? What kinds of conflicts contributed to me using
              in the past? ____________________________________________________________________



              There are other relapse situations that are not quite so common as the ‘Big
              Three’. Write personal examples of using next to these relapse situations.
              Pleasant Feelings - using substances to “celebrate” or try to get more of a good feeling.

              Urges and Cravings - having a sudden strong desire to use.

               Testing Personal Control - when people try using to see if they can now control their use, or
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             “handle” it this time.

             Feeling Bad Physically - when people try to make their physical pain or discomfort less through
             using.




             Module 33 Handout: High-Risk Situations




             Things to keep in mind when identifying my high risk situations:


             What places and social situations did I use in the most?




             What were the times of the day or week that I tended to use?




             What people, or kinds of people, did I use with the most?




             What things did I use to get high (drug paraphernalia, alcohol containers, etc.)?

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                                          Module 33 Main Points



      There are some situations that are more likely to lead to relapse than others.

      Three common situations are:

          o Feeling Bad

          o Social Pressures

          o Fights

      Questions to answer about your past high risk situations that can help you plan to avoid relapse:

          o Where did I use?

          o Who did I use with?

          o When did I use?




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                                                MODULE 34

                                              Relapse Set-Ups

             OBJECTIVES: 1. To help participants understand relapse setups and seemingly irrelevant
             decisions. 2. To help participants practice self-assessment through ABC behavior chains and
             develop alternative behaviors.

             CONTENT: This session helps participants learn more about relapse setups and
             seemingly irrelevant decisions, practice self-assessment through ABC behavior
             chains, and develop better ways of coping in the future.

             Say In Your Own Words:

             In today’s group we will review Relapse Setups and Seemingly Irrelevant Decisions (SID’s).

             Relapse Setups are when we set ourselves up for relapse. We do this by making a series of bad
             choices, which we convinced ourselves were harmless. These kinds of decisions are called
             Seemingly Irrelevant Decisions, when we put ourselves in high risk situations without noticing or
             admitting to ourselves that we are trying to give ourselves an excuse to relapse.

             We often engage in rationalization and try to make ourselves believe that going back around our
             drug or crime associates in the old neighborhood is not risky, when it really is.

             When we set ourselves up for relapse, it is usually a series of bad decisions
             that get us there. We can understand these decisions by looking at them in an ABC
             behavior chain. Remember, A stands for Antecedent, and means something that comes
             before the Behavior, which is what the B stands for. After the behavior is a
             Consequence, or what happens because of what we did. C stands for Consequence.

                    Go over first handout “ABC Behavior Chain - Example”.

             Let’s look at an example. Joe is in early recovery from substance abuse, mental illness,
             and criminal behavior; he has been released from our program and is starting to work again
             and get his life back together again. However, he missed his counseling appointment, and
             so he did not plan his weekend. He wakes up on Saturday and begins to feel bored and lonely
             because he has not planned any positive recovery activities for the weekend. He then begins
             to think about visiting his old drug and crime friends, “just to say hi”.



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             He knows that this is a high-risk situation for him, so he decides to just “walk past” the
             old neighborhood, since he needs to buy some toothpaste anyway, and he knows a store
             there where he can buy it. He walks through the old neighborhood, doesn’t see any of
             his friends, and manages to ignore several dealers who approach him and offer him
             drugs. He buys his toothpaste at the drugstore on the other side.

             He then walks back through the neighborhood, feeling proud of himself for
             not relapsing. He is so proud of himself, that he decides to knock on one of his
             old friend’s doors and brag a little bit about how he is doing well and is still
             sober. He knocks on his friend’s door, and there is a drug party going on.

             He is welcomed back into the group, and is quickly offered drugs, “for old time’s sake”.
             He thinks to himself that since he managed not to accept the dealer’s offers of drugs on the
             street, he must be strong enough now to control himself, and to just have one and then stop.
             Also, he tells himself that he doesn’t want to disrespect his old friends by turning down their
             offer of his drug of choice.

             So he agrees to take one, and before you know it, he has taken a bunch of drugs. This caused
             him to feel temporarily good, but quickly he crashes, and feels awful.

             The drugs run out, and so does the money, so his friends tell him to come with them and
             they can get some more. He does, and they end up robbing a convenience store to get
             more money. While they are running away from the store, they get caught by the police,
             and are arrested and charged with robbing the store. Since Joe has a record and was on
             parole, he is re-sentenced and sent back to prison.

                    Have participants answer the handout’s questions about Joe.

                    Go over handout “ABC Behavior Chain- Self-Assessment”

                    Have participants fill out each part, and share their answers with the group.

                    If individuals get stuck, involve the group in helping them come up with ideas.




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             Module 34 Handout: ABC Chain

                    Antecedent                      Behavior                       Consequence

                                                                                   Joe felt lonely and bored on
                                                                                   Saturday morning and
                    1.Joe missed his counseling     Joe did not plan his           thought about visiting his
                    session during the week.        weekend                        old friend.
                    2. Joe rationalizes his visit
                    to the old neighborhood by                                     Joe manages to not buy
                    telling himself that he needs   Joe walks through the old      drugs from the dealers and
                    to get toothpaste there.        neighborhood.                  buys toothpaste.
                                                    He decides to knock on his
                    3. Joe feels overconfident      old friend's door to brag      Joe enters the apartment
                    about not buying from the       about how ell he is doing in   where a drug party is going
                    dealers.                        recovery.                      on.
                                                                                   Joe feels good for a
                    4. Joe gets offered drugs                                      moment. Then he feels
                    and feels that he now has it                                   really bad about using and
                    under control and can stop                                     wants more of the drug to
                    after just one.                 Joe takes one hit.             try to feel better.
                    5. Joe feels bad about                                         Joe "crashes" and feels
                    using.                          Joe takes more drugs.          terrible.
                    6. The drugs and money
                    run out and friends invite      Joe goes with his friends
                    him to help them get more       and ends up ribbing a          Joe is arrested and sent to
                    money for drugs.                convenience store.             prison.




             1. How did Joe set himself up for relapse?


             2. What were some Seemingly Irrelevant Decisions (SID’s) that he tricked himself into
             making? How did he rationalize these decisions?


             3. What were some errors in thinking that led him to relapse?



             4. For each of numbers 1-6, what positive behaviors could he have done instead to keep
             himself from relapsing?

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             Module 34 Handout: ABC Chain


                    Antecedent               Behavior           Consequence




                                                                .




             1. How did you set yourself up for relapse?


             2. What were some Seemingly Irrelevant Decisions that you tricked yourself into
             making? How did you rationalize these decisions?



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             3. What were some errors in thinking that led you to relapse?



             4. For each of numbers 1-6, what positive behaviors could you have done instead to
             keep yourself from relapsing?



                                          Module 34 Main Points



      Relapse doesn’t “just happen”. There are a series of decisions that lead to it.

      To prevent future relapse, it helps to look at past relapses and the thought chains that led to
      using again.

      Often, there are many points among the path to relapse where a different, positive choice could
      have been made that would have prevented relapse.




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                                              MODULE 35
                            Self Monitoring for Signs of Relapse: Substance Abuse


             OBJECTIVES: 1. To help participants identify their past and present early warning signs of
             relapse into substance abuse. 2. To help participants identify common themes among the group’s
             early warning signs.

             CONTENT: This session helps participants identify their past and present early warning
             signs of relapse into substance abuse, and also identify common themes among the
             group’s early warning signs.

             Say In Your Own Words:

             In an earlier session, we looked at a past relapse episode and broke it down into
             Antecedents, Behaviors, and Consequences. This helped us see how a relapse is usually
             the end result of a whole chain of bad decisions. Some of these decisions may seem
             harmless, and that’s what we tell ourselves as we are making them.

             This is how we trick ourselves and set ourselves up for relapse, by making a series of
             bad choices which put us in one of our high-risk situations. These bad choices that set
             us up for relapse are called Seemingly Irrelevant Decisions, because we trick ourselves
             into thinking that they don’t matter, but they do.

             Remember, people in this program need to try to prevent three different kinds
             of relapse: mental illness, substance abuse, and criminal behavior. Today we
             are going to look at our Early Warning Signs for relapse into substance abuse.

                    Go over handout “Early Warning Signs for Substance Abuse Relapse”

             Instructions for handout:

             Read through the following common Early Warning Signs for Substance Abuse
             Relapse. If you have had other Early Warning Signs that are not on the list, write
             those in on the blank lines after the word “other” in the right category. If you add
             them in, make them as specific as possible as to what your Early Warning Signs
             were.

             Circle the Early Warning Signs you have experienced in the past that happened before
             and during your relapse into substance abuse.

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             Put a check mark next to those that you have experienced recently during your
             stay here.



                    Now ask participants to share answers, and identify common themes by
                    writing them on the board.

                    Take a look at the handouts to see if there are any problematic Early
                 Warning Signs that need to be dealt with right away, and take appropriate
                 action either in group or afterwards, or both.

                    Use the group as necessary to help individuals that need immediate
                    assistance.


             Remember, the reason we are figuring out these early warning signs is so that we can
             recognize them when they come up next time and do something to stop them from
             becoming a full-blown relapse into substance abuse.

             Next group we will focus on what to do when we notice that our early warning signs
             are coming up, so make sure to keep your handout in your notebook and bring it to
             next group.




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             Module 35 Handout: Early Warning Signs for Substance Abuse Relapse


             Read through the following common Early Warning Signs for Substance
             Abuse Relapse.

                       If you have had other Early Warning Signs that are not on the list, write
                       those in on the blank lines after the word “other” in the right category. If
                       you add them in, make them as specific as possible as to what your Early
                       Warning Signs were.

                       Circle the ones you have experienced in the past that happened before
                       and during your relapse into substance abuse.

                       Put a check mark next to those that you have experienced recently
                       during your stay here.

             1) Attitude and Thinking changes

                 a) Losing interest in your recovery plan
                 b) Thinking that you can use some alcohol or drugs and stay in control
                 c) Urges and impulses to use drugs or alcohol
                 d) Remembering only the pleasurable part of addiction, and forgetting about
                    the pain
                 e) Making Seemingly Irrelevant Decisions that put you in high risk situations
                 f) Not caring about yourself and what happens in your life
                 g) Other___________________________________________________
                 h) Other___________________________________________________


             2) Mood or Emotional changes
                a) Feeling sad, depressed, or hopeless- feeling like giving up
                b) Becoming too energetic, excited and feeling “on top of the world”
                c) Feeling anxious, nervous, restless or on edge
                d) Feeling bored, empty, or lonely
                e) Feeling lost, aimless, or without any direction
                f) Feeling angry and hating other people

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                 g) Feeling distrustful and suspicious of others
                 h) Feeling negative, cynical, or pessimistic
                 i) Other___________________________________________________
                 j) Other___________________________________________________




             Module 35 Handout: Early Warning Signs for Substance Abuse Relapse


             3) Behavior Changes

                 a) Cutting down or stopping AA, NA, dual recovery, or other support group
                    meetings
                 b) Cutting down or stopping regular contact with your sponsor or recovery
                    group
                 c) Missing counseling appointments without calling in
                 d) Missing other appointments or work without calling in
                 e) Withdrawing from other people and keeping to yourself
                 f) Arguing and getting into fights more with others
                 g) Putting yourself in high risk situations, where there is pressure to use
                 h) Stopping exercise or meditation program, stopping healthy hobbies
                 i) Other___________________________________________________
                 j) Other___________________________________________________


             4) Changes in Daily Living or Physical Changes

                 a) Trouble falling asleep or staying asleep; starting to sleep too much
                 b) Changes in appetite; weight loss or weight gain
                 c) Change in personal hygiene habits (stop showering, brushing teeth, shaving,
                    etc.)
                 d) Changes in energy level (much higher or lower than usual)
                 e) Other___________________________________________________
                 f) Other___________________________________________________




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                                         Module 35 Main Points



      There are early warning signs before a substance abuse relapse occurs.

      If you know your personal warning signs, it is easier to avoid relapse.

      Some common types of warning signs include:

          o Attitude and Thinking Changes

          o Mood or Emotional Changes

          o Behavioral Changes

          o Changes in Daily Living or Physical Changes




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                                                              MODULE 36

                                        Recognizing Early Warning Signs of Relapse


             OBJECTIVES: 1. To review the relapse prevention process 2. To introduce the concepts of
             “Seemingly Irrelevant Decisions” or SIDs and early warningsigns for relapse

             CONTENT: This session focuses on understanding the relapse prevention process
             and the importance of identifying early warning signs and high-risk situations.
             Say in Your Own Words:

             People often believe that relapses just happen.       They don’t understand it. They
             had no desire to drink or take drugs but just happened to find themselves in
             a bar or in the old neighborhood; and the lapse just “happened.” Actually,
             whether conscious or unconscious, the relapse was due to a series of small decisions
             that happened much earlier, which led the person into a relapse “trap.”

             A “relapse trap” is a situation that is destined to result in a relapse unless
             strong action is taken. It is a trap because all of the cues and social pressure
             in the situation press for doing the problem behavior.       Finding yourself in a
             bar surrounded by your old friends that still continue to use, and you sitting
             there feeling depressed and in need of excitement almost guarantees that
             you’ve been trapped into a relapse.        But, it is the decisions that you made
             much earlier that resulted in you trapping yourself.         The decision to stop
             meditating, the decision to miss your therapy appointment, the decision to not
             go to work that day, and the decision to look up an old friend that you used to
             use with, are small decisions that set you up for the relapse trap. These
             “Seemingly Irrelevant Decisions” 49 or SIDs are the small, even minor,
             decisions made over a period of time and are the most dangerous.

             Marlatt and Gordon also developed a Model of Relapse Set-ups that provides
             insight into the relapse process and these “seemingly irrelevant decisions.”




             49
                  Adapted from Marlatt, G.A., & Gordon, J.R., Relapse Prevention. New York: Guilford Press, 1985.




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                     Review the Marlatt Model as follows with the group.

             1. Lifestyle Imbalance. Many people believe that a balanced lifestyle is the
                key to a healthy, successful life. The proper balance of work, play,
                exercise, nutrition, sleep, meditation and relaxation, time with friends/
                family, and attending to spiritual needs is imperative. For participants in
                this program, we add to this list regular visits to probation officers,
                counselors, medical doctors and/or psychiatrists. When any one piece gets
                out of balance, we begin to become vulnerable to the start of a relapse
                process. It is common for each of us to get discouraged, and say to
                ourselves, “What’s the sense?” It’s easy for ex-prisoners in particular to
                see the world as a hostile place, the future as rather bleak if not hopeless,
                and themselves as worthless. When this happens, we often unconsciously
                decide to “give up” and then decide to miss therapy appointments, stop
                taking medication, or go back to old patterns. We “forget” to practice
                meditation, to exercise, and to visit our healthy friends. In a word, we get
                into a rut.

             2. Desire for Indulgence. When we’re in a rut, it’s natural to want to indulge
                ourselves, give ourselves a little pleasure, take away our depression and
                pain, or express our hostility. Particularly if we’ve been addicted to
                substances, the desire to indulge ourselves becomes strong.

             3. Urges and Impulses to use Substances, Neglect Mental Health Needs,
                and/or Commit Crimes. Very quickly, desires turn into urges and
                impulses, even if at the unconscious level. We experience a set of “early
                warning signs” like feeling depressed, wanting to miss AA or NA meetings,
                missing therapy appointments, feeling everyone is out to get us, and a
                variety of other signs.

             4. Rationalization and Denial. There is a natural tendency to ignore these
                early warning signs. Sometimes it is a direct denial that a problem exists.
                More often, we rationalize the early warning signs as not meaning what
                they mean. Our mind tricks us into believing that we'll be better off
                without our medication, or that one drink won’t really hurt, or that we
                need a day off of work to restore our mental health. We may even come to
                believe that our families are “pains in the butt.” In other words, we begin
                talking ourselves into believing that we need a drink, we’d be “better off”
                without medication, or that “just the one time” we will commit a crime and
                it will be okay.
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             5. The Seemingly Irrelevant Decision. We make decisions that bring us one
                step closer to a relapse. The small step, a mundane choice, the small
                decision lead us to a high-risk situation. For example, which of the
                following small decisions place us in high-risk situations? Why/ why not?

                            a. Deciding to keep liquor in our place for friends.
                            b. Going to bars to play darts.
                            c. Going to visit old drinking friends.
                            d. Going to a party where people are drinking.
                            e. Planning how to spend the weekend.
                            f. Starting a conversation with friends at an AA or NA meeting.
                            g. Going back to the old neighborhood.
                            h. Telling a friend that you’ve decided to quit drinking.
                            i. Asking housemates not to bring alcohol into the house.
                            j. Withdrawing from friends and going out by yourself late at night.
                            k. Participating in regular exercise.
                            l. Deciding that you don’t need counseling anymore.

             The question is, “Where will each of the above decisions lead?”

                     How much time you spend here depends on how much time is left in
                     the session.    If a lot of time remains, have members of the group
                     generate their own list of “SIDs.”

             6. Exposure to High-Risk Situations: As determined above, SIDs will lead us
                into high-risk situations where the cues, urges, and impulses will pull us
                towards using substances, neglecting mental health needs, and/or
                committing crimes.

             The major purpose of this unit was to help everyone become aware of early warning
             signs for relapse in each of the areas. A “Top Ten” list can help us recall important
             information easily. We’ve provided “Top Ten” Warning Sign lists that can alert
             us to the fact that we are becoming vulnerable to a relapse. Naturally, there is
             overlap between early warning signs for using substances, neglecting mental health
             needs, and committing crimes. But each area has its own set of specific warning signs.

             In upcoming sessions, we will examine each of these early warning signs.
             We’ll use “relapse stories” specifically to determine your personal “warning
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             sign” lists and practice healthy coping skills to help re-write the relapse story
             into an effective, healthy coping story. We also will prepare a list of personal “high-
             risk situations” for which we’ll develop and practice “emergency plans” that either get
             us out of the situation or help us cope with it in order not to relapse.


             Module 36 Handout: Relapse Set-Ups


             1. Lifestyle imbalance


             2. Desire for indulgence


             3. Urges and impulses to go off medication or neglect mental health
                needs, do substances, and/or commit crimes


             4. Rationalization and denial


             5. The Seemingly Irrelevant Decision(s)—(SIDs)


             6. Exposure to high-risk situations




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             Adapted from Marlatt, G.A., & Gordon, J.R., Relapse Prevention. New York: Guilford Press, 1985.




                                                  Module 36 Main Points



      Relapse is due to a series of small decisions that happen much earlier, which lead the person into a
      relapse “trap.”

      A “relapse trap” is a situation that is destined to result in a relapse unless strong action is taken.

      Common relapse traps:

          o Lifestyle imbalance

          o Desire for indulgence

          o Urges and impulses to go off medication or neglect mental health needs, do substances,
            and/or commit crimes

          o Rationalization and denial

          o The Seemingly Irrelevant Decision(s)—(SIDs)

          o Exposure to high-risk situations




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                                               MODULE 37
                                      Self Assessment of Life Goals


             OBJECTIVES: 1. To emphasize the importance of life goals in the relapse process.
             2. To examine the potential impact of relapse on achieving life goals 3. To have participants
             identify their personal life goals

             CONTENT: This session introduces participants to self-assessment of life goals, a
             strong motivating force to remain substance free, law abiding, and mentally
             healthy.

             Say in Your Own Words:

             One of the strongest motivations we as humans have is the search for meaning and
             life satisfaction. There are some areas of your life that need to be managed
             well in order for you to achieve your goals and to experience satisfaction. On
             the other hand, relapse is a process that blocks or interferes with our achieving life
             satisfaction.

             When anyone who has struggled with relapse is asked, “Why do you want to remain
             clean and sober, mentally healthy, and/or stay out of jail?” they usually cite one
             or more of their Life Goals. They say “I love my family; I want to do it for
             them” or “I have so much potential; I want to be a photographer and take
             beautiful pictures.” Others will cite spiritual goals such as “being right with the
             Lord,” or social or parenting goals. Hence, life goals both guide and motivate us.

             The experience of lack of meaning or goals has been cited as the one of the
             reasons that people do relapse. “I am bored,” “I feel like I’m in a rut,” “There
             is nothing to live for,” are things we hear before a person experiences a
             relapse to substance abuse, criminal activity, or neglecting mental health
             needs.

                    Point out the Life Goals Worksheet for each participant to complete.

             This worksheet presents a format to identify your own life goals for each of
             the areas of marriage and family, school and work, social and friendship,




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             leisure time and recreation, personal development, spiritual and emotional goals.

             Remember to write out smaller goals that you’ll need to meet in order to obtain
             larger goals. Be sure they are 1) realistic and achievable and 2) broken down into
             short, intermediate, and long term.

             For example, under School and Work goals, don’t go directly to something like
             “Obtain my Ph.D. in physics.” Rather, a sequence of goals is appropriate. These could
             be: 1) Obtain my GED; 2) Attend a community college to achieve my Associate’s
             Degree; 3) Earn my Bachelor of Science in physics at Florida State; 4) Work and
             attend graduate school part time to earn Master’s Degree in physics; and 5) Complete
             my Ph.D. in physics.

             For Marriage, the goal should not be “Find a woman and get married.” Rather,
             write a sequence of goals, such as: 1) Meet a healthy member of the opposite sex; 2)
             Begin a dating relationship; 3) Work on developing healthy intimacy and a healthy
             relationship free of substances; and 4) Explore the possibility of marriage.

                    Instruct the participants to follow this process for each area. After goals have
                    been identified, lead a discussion of some of the goals that they identified.




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             Module 37 Handout: Life Goals
             LIFE GOALS

             Imagine how you want your life to be five years from now with regard to work, play,
             relationships with others, and your relationship to yourself. Now, think of the small goals that
             you will need to achieve to make these life goals come true. For example: If you see yourself
             working as a computer specialist five years from now, your goals might be: 1) Earn my GED; 2)
             Attend technical school to learn basic computer skills; 3) Take an entry-level position to gain
             computer programming experience; and 4) Work for a top computer software company.


             A. Marriage and/or Family Goals: How would you like to develop or strengthen your family
                relationships? Include sharing of activities and the development of closeness.

                 1. ______________________________              2. _____________________________

                 3. ______________________________              4. _____________________________

                 5. ______________________________              6. _____________________________

                 7. ______________________________              8. _____________________________

             B. School and Work Goals: What are your school, work, and job objectives, both short-term
                and long-term?

                 1. ______________________________              2. _____________________________

                 3. ______________________________              4. _____________________________

                 5. ______________________________              6. _____________________________

                 7. ______________________________              8. _____________________________

             C. Social and Friendship Goals: What are your goals with regard to friends and social
                activities? What groups or clubs or other organizations do you want to be part of?

                 1. ______________________________              2. _____________________________

                 3. ______________________________              4. _____________________________

                 5. ______________________________              6. _____________________________

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                 7. ______________________________               8. _____________________________




             Module 37 Handout: Life Goals


             D. Leisure Time and Recreation Goals: What do you want to do with your free time?        What
                hobbies, sports, or interests do you want to develop?

                 1. ______________________________               2. _____________________________

                 3. ______________________________               4. _____________________________

                 5. ______________________________               6. _____________________________

                 7. ______________________________               8. _____________________________

             E. Personal Development Goals: What new attributes do you want to develop in yourself?
                Strengthen? Decrease?

                 1. ______________________________               2. _____________________________

                 3. ______________________________               4. _____________________________

                 5. ______________________________               6. _____________________________

                 7. ______________________________               8. _____________________________

             F. Spiritual Goals: What would you like to see happen with your spiritual life?

                 1. ______________________________               2. _____________________________

                 3. ______________________________               4. _____________________________

                 5. ______________________________               6. _____________________________

                 7. ______________________________               8. _____________________________

             G. Emotional Goals: What emotions do you want to handle better? What feelings do you want
                to feel more? Feel less?

                 1. ______________________________               2. _____________________________

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                 3. ______________________________         4. _____________________________

                 5. ______________________________         6. _____________________________

                 7. ______________________________         8. _____________________________




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                                          Module 37 Main Points



      Having goals is a vital part of a healthy recovery.

      Without goals, people begin to get bored and feel that life is pointless. This can lead to relapse.

      You should have goals in a variety of categories including:

          o Marriage and/or Family

          o School and Work

          o Social and Friendship

          o Leisure Time and Recreation

          o Personal Development

          o Spiritual

          o Emotional




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                                               MODULE 38
                            Self- Monitoring for Signs of Relapse: Mental Illness

             OBJECTIVES: 1. To help participants identify the early warning signs of a relapse of mental
             health disorder symptoms 2. To help participants identify their own attitudinal, mood,
             behavioral, and daily routine changes that could signal trouble for mental health disorder
             symptoms relapse

             CONTENT: This session helps participants to identify the early warning signs that
             signal a potential relapse of mental health disorder symptoms.

                    Point out the Warning Signs Handout. You will be reviewing each of the early
                     warning signs by category (i.e., Attitudinal Changes, Mood Changes, etc.).

             Say in Your Own Words:

             Today we are going to talk about some of the Warning Signs for a
             Relapse of Mental Health Disorder Symptoms. You can see that they are
             grouped into categories: Changes in Attitude and Thoughts; Changes in
             Moods or Emotions; Changes in Behavior; and Changes in Daily Living.

             As we go through this list, think about how each specific warning sign can
             eventually lead to a mental health disorder relapse. Notice that if you ignore these
             early warning signs, you’ll be moving along the road to relapse.


             1. What changes in your attitude or thoughts might lead you to a relapse of
                mental health disorder symptoms? For example, would “losing interest in
                your treatment plan” be a warning sign? (Allow time for discussion on each
                point.) What about deciding on your own that you “no longer need
                counseling or meds?” Would “not caring about your self or what happens
                in your life” lead to a mental health disorder relapse? Thinking of hurting
                your self or someone else would be a warning sign of a relapse as well
                (discuss). And those “Seemingly Irrelevant Decisions” (SIDs) that we
                discussed yesterday morning, the small decisions you made over time that put you
                in high-risk situations, are relapse traps. It would help you to recognize them
                as “early warning signs” of a relapse of mental health disorder symptoms
                (discuss).

             2. Next we’ll talk about some examples of mood or emotional changes that
                may lead you to a relapse of mental health disorder symptoms. Why do
                you think feeling sad or depressed or feeling energetic, excited, or on-top-
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                 of-the-world might be warning signs of relapse? (Allow for discussion.)


                 What about feeling anxious, nervous, or on-edge? What happens when we feel
                 bored, restless, or empty? Is it likely that when our emotions turn to anger and
                 hate that we are experiencing an important warning sign? The same could be said
                 if our mood changes to being distrustful or suspicious of others. (Allow for
                 discussion before moving on.)

             3. What do you think are some behavioral changes that may indicate you are
                on the road to relapse? If you were to act on the attitude/thought change
                we mentioned earlier, “I don’t need my meds anymore,” and then cut
                down or quit your meds without talking with your mental health care
                provider, you would be on the road to relapse. (Again, allow for discussion.)
                Why wouldn’t you want to withdraw from others and keep to yourself?
                Here is another early warning sign: you might notice that lately you get
                into arguments with others much more frequently. Or you actually miss
                those therapy appointments. These are all behavioral changes that we call
                early warning signs of relapse. (Allow for discussion before moving on.)

             4. The last category we will discuss this morning describes changes in daily
                living activities that are early warning signs of a relapse. If you notice a
                change in your sleeping habits, such as trouble falling or staying asleep,
                you may be on the road to relapse. (Discuss each example with the group.)
                These changes should not be ignored, but recognized, identified, and
                managed through coping techniques we will discuss later.             What if you or
                someone who is close to you notices a change in your personal hygiene
                habits? You might see a big change in your energy level, that is, much more
                or less energy that you usually have. Can you think of any other early
                warning signs in the category of changes in daily living activities?

                    After becoming familiar with the general set of early warning signs, the
                    participants can complete a Self-Assessment for relapse of mental health
                    disorder symptoms using the “Relapse Story” technique.

             Now we’ll get a chance to look at those early warning signs and how they work in
             our own lives. Here are some guidelines that will help you to write a story of your
             own.

             Think about the last time that your mental health was stable.    Write it down under
             number 1.

             Following these guidelines, write about the healthy behaviors in which you were
             engaged at the time.
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             Then, describe the step-by-step process that culminated (resulted) in a relapse of mental
             health disorder symptoms.




                    Ask each participant to write his or her own brief story about his/her latest
                    mental health disorder symptoms relapse.

                    If a participant has not had a relapse, ask him or her to write about an
                    imaginary relapse that “could” have happened to them. They can refer to the
                    Early Warning Sign list for examples of changes that signal a relapse.




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             Module 38 Handout: Top Early Warning Signs

             THE WARNING SIGNS FOR RELAPSE OF MENTAL HEALTH DISORDER SYMPTOMS



             1. Attitudinal and Thought Changes

                    a. Losing interest in your treatment plan
                    b. Thinking that counseling and/or medication is not needed anymore
                    c. Not caring about yourself and what happens in your life
                    d. Thinking of hurting yourself or someone else
                    e. SIDs



             2. Mood or Emotional Changes

                    a. Sad or depressed
                    b. Energetic, excited, on top of the world
                    c. Anxious, nervous, on edge
                    d. Bored, restless, or empty
                    e. Angry and hate other people
                    f. Distrustful, suspicious of others



             3. Behavioral Changes

                    a. Cutting down on medication without discussion with therapist or doctor
                    b. Withdrawing from other people and keeping to yourself
                    c. Arguing more with others
                    d. Missing therapy appointments


             4. Changes in Daily Living

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                    a. Trouble falling asleep or staying asleep
                    b. Change in personal hygiene habits
                    c. Big change in energy level (much higher or lower than usual)




             Module 38 Handout: Relapse Story-Part1

             RELAPSE STORY GUIDELINES -
             MENTAL HEALTH DISORDER SYMPTOMS (Part 1)




             1. The last time my mental health was stable was:



             2. The things that I did to help myself be stable were:



             3. The things in the chain that caused me to relapse were:



             4. The first change that happened was:



             5. I stopped or cut back on my medication because I thought:



             6. Where did it lead?




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                                         Module 38 Main Points



      There are early warning signs before a mental health relapse occurs.

      If you know your personal warning signs, it is easier to avoid relapse.

      Some common types of warning signs include:

          o Attitude and Thinking Changes

          o Mood or Emotional Changes

          o Behavioral Changes

          o Changes in Daily Living or Physical Changes




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                                            MODULE 39
                            Early Warning Signs of Mental Illness Relapse


             OBJECTIVES: 1. To help participants recognize the kinds of situations that can begin the
             process of mental health disorder symptom relapse 2. To analyze past “stories” in order to
             understand relapse “traps” 3. To have each participant create a list of high-risk situations and
             early warning signs that can begin the process of mental health disorder symptom relapse

             CONTENT: This session helps participants identify the relapse traps that were
             present during their personal mental health disorder relapses described in the morning
             session.


             Say in Your Own Words:

             Now we will be looking at your mental health disorder relapse story. Our first step
             will be to analyze the past mistakes from your relapse story. Recognizing and
             discussing our mistakes will help us all learn from them.

             What were some of the Warning Signs that were missed? What were the SIDs in the
             story? Which decisions were mistakes?

                    Have one or two of the participants read their relapse story and their
                     analysis of past mistakes. This should help everyone learn from their own
                     and others’ mistakes.


             Now, you will have an opportunity to Rewrite Your Relapse Story using the
             following guidelines for the same situation. These guidelines should help you imagine
             future challenges you’re likely to face and practice coping effectively in those high-
             risk situations.



                    Walk the participants through each guideline so that they write a response to
                    each item on their Relapse Story (Part 2) paper.




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             Complete the Mental Health Disorder Symptoms Relapse Story Part 2 by writing
             your responses to the following statements.

             a. I recognized the first early warning sign ________________. What was it?

             b. I identified my situation as high-risk ______. Write down how you did this.

             c. I coped with the situation by ________________. What did you do to cope?

             d. The things that I learned about this situation were _______. Write it down.

             e. I rewarded myself for having coped successfully by _____.              How did you
                reward yourself?

             This is your Relapse Story rewritten to remind you of successful coping and to help you
             in the future to cope with those high-risk situations.

                    Teach the participants to anticipate potential future challenges through
                    relapse fantasies in which they practice coping effectively in high-risk
                    situations.

                    Now, have each participant create a list of his/her own high-risk situations
                    that can begin the process of mental health disorder symptom relapse as well
                    as their personal early warning signs.

             Finally, you will create a list of your own high-risk situations. At the top of
             the page, write “My High-Risk Situations for Mental Health Disorder
             Symptom Relapse”.         You can start with the situation we just used as an
             example. Then think of other situations that put you at risk of relapsing into mental
             health disorder symptoms.

                   Allow time to complete. Provide guidance and refer to previous
                 worksheets/handouts as needed.

             On a separate page or on the back, create a list of your own personal early warning
             signs to mental health disorder symptoms relapse. At the top of the page, write “My
             Early Warning Signs for Mental Health Disorder Symptoms Relapse”. You can look
             back to the examples on the Top Warning Signs handout that we used earlier.



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             Module 39 Handout: Relapse Story-Part 2

             RELAPSE STORY GUIDELINES -
             MENTAL HEALTH DISORDER SYMPTOMS (Part 2)




             1. I recognized the first early warning sign:




             2. I identified my situation as high-risk:




             3. I coped with the situation by:




             4. The things that I learned about this situation were:




             5. I rewarded myself for having coped successfully by:




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                                          Module 39 Main Points



      Looking at past relapses is a good way to learn what not to do.

      You should also anticipate new situations

      It is important to “rehearse” potential relapse situations. By thinking about potential situations and
      deciding on plan of action BEFORE you encounter these situations, you are more likely to make
      correct and safe decisions.




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                                              MODULE 40
                            Identifying Early Signs of Criminal Behavior Relapse


             OBJECTIVES: 1. To help participants identify the early warning signs of a return to criminal
             behavior 2. To help participants identify their own attitudinal, mood, behavioral, and
             daily routine changes that could signal trouble for a criminal behavior relapse

             CONTENT: This session helps participants to identify the early warning signs that
             signal a potential relapse into criminal behavior.


                    Point out the Warning Signs Handout. You will be reviewing each of the early
                    warning signs for criminal behavior relapse by category (i.e., Attitudinal
                    Changes, Mood Changes, etc.).

             SAY IN YOUR OWN WORDS:

             Here are some of the Warning Signs that you might be heading towards a relapse
             into criminal behavior. They are grouped into the same categories we reviewed for
             mental health disorder symptoms and substance abuse: Changes in Attitude and
             Thoughts; Changes in Moods or Emotions; Changes in Behavior; and Changes in
             Daily Living.

             As we go over this list, think about how each specific warning sign can
             eventually lead to criminal behavior relapse. Note that if you ignore the early warning
             sign, then you’re moving along the “road to relapse”.


                    Refer to the Warning Signs Handout for discussion. Review each example
                    from each category with the group. Note that most of the warning signs are
                    different, now targeted to criminal behaviors. Allow sufficient time for
                    discussion of each.

                    After becoming familiar with the general set of warning signs for criminal
                    behavior relapse, participants can complete another Self-Assessment, this
                    time for relapse into criminal behavior, following the “Relapse Story”
                    technique.




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             Now we’ll get a chance to look at those early warning signs for criminal
             behavior relapse and how they work in our own lives.            Here are some
             guidelines that will help you write a story of your own about your latest relapse
             into criminal behavior.

             Think about the last time you were behaving in law-abiding ways.        Write it down
             under number 1.

             Following these guidelines, write the healthy behaviors in which you were
             engaged at the time; that is, what helped you to stay away from criminal
             behavior?

             Then, describe the step-by-step process that culminated (resulted) in a
             relapse. Use statements 3 through 6 to help you write the process.


                    Each participant will write a brief story about his/her latest criminal
                    behavior relapse.



             If a participant has not had a relapse, ask him or her to write about an imaginary
             relapse that “could” have happened to them. They can refer to the warning sign list for
             examples of changes that signal a relapse into criminal behavior.




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             Module 40 Handout: Top Early Warning Signs
             THE TOP WARNING SIGNS
             FOR RELAPSE INTO CRIMINAL BEHAVIOR

             1. Attitudinal and Thought Changes
                    a. Losing interest in your recovery plan
                    b. Thinking of ways that you can take advantage of others or break the law
                    c. Not caring about yourself and what happens in your life
                    d. Believing that your troubles are over
                    e. Believing “just this time”
                    f. SIDs

             2.     Mood or Emotional Changes
                    a. Sad or depressed
                    b. Energetic, excited, on top of the world
                    c. Anxious, nervous, on edge
                    d. Bored, restless, or empty
                    e. Angry and hate other people
                    f. Distrustful, suspicious of others
                    g. Lonely
                    h. Bitter

             3.      Behavioral changes
                     a. Cutting down or stopping AA, NA, dual recovery, or support group
                    b. Cutting down/ stopping regular contact with your sponsor or support group
                    c. Withdrawing from people and keeping to yourself
                    d. Arguing more with others
                    e. Missing therapy appointments
                    f. Cutting down or stopping hobbies and enjoyable activities
                    g. Placing yourself in situations where there is pressure to break the law
                    h. Withdrawing from people and keeping to yourself
                    i. Getting involved in petty crimes
                    j. Avoiding responsibility
                    k. Feeling entitled

             4.     Changes in daily living
                    a. Sleeping a lot less or more than usual
                    b. Change in personal hygiene habits
                    c. Big change in regular routines for the day or week


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             Module 40 Handout: Relapse Story-Part 1

             RELAPSE STORY GUIDELINES -
             CRIMINAL BEHAVIOR (Part 1)




             1. My most recent attempt to stop doing criminal behavior was:



             2. The things that I did to help stay away from criminal behavior
                were:



             3. The things in the chain that caused me to go back to criminal
                behavior were:



             4. The first change that happened was:



             5. I conned myself that things were okay by thinking:



             6. Where did it lead?



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                                         Module 40 Main Points



      Just like with substance abuse and mental illness, there are early warning signs before a criminal
      behavior relapse occurs.

      If you know your personal warning signs, it is easier to avoid relapse.

      Some common types of warning signs include:

          o Attitude and Thinking Changes

          o Mood or Emotional Changes

          o Behavioral Changes

          o Changes in Daily Living




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                                             MODULE 41
                            High-Risk Situations for Criminal Behavior Relapse


             OBJECTIVES: 1. To help participants recognize the kinds of situations that can begin the
             process of a criminal behavior relapse 2. To analyze past “stories” in order to understand
             relapse “traps” 3. To have each participant create a list of high-risk situations and early
             warning signs that can begin the process of criminal behavior relapse

             CONTENT: This session helps participants identify the relapse traps that were
             present during their personal criminal behavior relapses described in the morning
             session.

             During this session, the participants analyze their criminal behavior relapse story in
             order to define specific relapse traps that pertain to them and then rewrite their story in
             order to begin the practice of coping effectively in high-risk situations.

             Say in Your Own Words:

             Now we will be looking at your criminal behavior relapse story from last session.
             Our first step will be to analyze past mistakes to help us all learn from them.

             What were some of the Warning Signs that were missed? What were the SIDs in the
             story? Which decisions were mistakes?

                    Have one or two of the participants read their relapse story and his or her
                    analysis of past mistakes. This should help everyone learn from their own and
                    others’ mistakes.


             Next, you will have an opportunity to Rewrite Your Criminal Behavior
             Relapse Story using the following guidelines for the same situation. These
             guidelines help you to imagine future challenges you’re likely to face and practice
             coping effectively in those high-risk situations.

                    Walk the participants through each guideline so that they write a response to
                    each item on their Relapse Story (Part 2) paper.




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             Complete the Relapse Story Part 2 by writing your responses to the following
             statements.

             a. I recognized the first early warning sign ________________. What was it?

             b. I identified my situation as high-risk ______. Write down how you did this.

             c. I coped with the situation by ________________. What did you do to cope?

             d. The things that I learned about this situation were _______. Write it down.

             e. I rewarded myself for having coped successfully by ______.             How did you
                reward yourself?

             This is your Relapse Story rewritten to remind you of successful coping and to help you
             in the future to cope with those high-risk situations.

                    Teach the participants to anticipate potential future challenges through
                    relapse fantasies in which they practice coping effectively in high-risk
                    situations.

                    Now, have each participant create a list of his/her own high-risk situations
                    that can begin the process of criminal behavior relapse as well as their
                    personal early warning signs.

             Finally, you will create a list of your own high-risk situations. At the top of the
             page, write “My High-Risk Situations for Criminal Behavior”. You can start with
             the situation we just used as an example. Then think of other situations that put
             you at risk of relapsing into criminal behavior.

                    Allow time to complete. Provide guidance and refer to previous
                    worksheets/handouts as needed.

             On a separate page or on the back, create a list of your own personal early warning
             signs for relapse. At the top of the page, write “My Early Warning Signs for
             Criminal Behavior”. You can look back to the examples on the Warning Signs
             handout that we used earlier.


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               Module 41 Handout: Relapse Story-Part 2


             RELAPSE STORY GUIDELINES -
             CRIMINAL BEHAVIOR (Part 2)




             1. I recognized the first early warning sign:




             2. I identified my situation as high-risk:




             3. I coped with the situation by:




             4. The things that I learned about this situation were:




             5. I rewarded myself for having coped successfully by:




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                                          Module 41 Main Points



      Looking at past relapses is a good way to learn what not to do.

      You should also anticipate new situations

      It is important to “rehearse” potential relapse situations. By thinking about potential situations and
      deciding on plan of action BEFORE you encounter these situations, you are more likely to make
      correct and safe decisions.

      Criminal thinking errors need to be challenged.

      Just like other relapses, relapse into criminal behavior starts with “small” things. Things like lying
      about why you are late for work, eating your roommate’s food without permission, etc…

      Learning how to be “a more successful criminal” from your cellmate is not a wise choice. After all,
      he is sitting right next to you, isn’t he? How “successful” was he?




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                                                 MODULE 42

                                Triggers, Cravings, Urges- Revisited


             OBJECTIVES: 1. To define cravings, urges, and triggers. 2. To help participants identify
             different types of cravings, urges, and triggers. 3. To help participants identify their own triggers.

             CONTENT: This session defines and classifies cravings, urges and triggers, and
             helps participants develop coping strategies and skills to manage them.

             Say In Your Own Words:

             The topic for this group is Identifying Triggers, Cravings and Urges. First of all, let’s
             define what cravings and urges are. What do you think they are?

                    Solicit definitions and examples from group.

             Cravings and urges can fall into several categories. Cravings are usually felt in the
             body, and are strong desires to use alcohol or drugs.

             Urges include feelings and thoughts associated with wanting to do something, which
             might mean wanting to use alcohol or drugs, or with wanting to perform criminal
             behavior, or with wanting to make other destructive, impulsive behaviors, such as
             stopping counseling sessions, or stopping medication for mental illness.

             These cravings and urges can also be classified by what is the trigger or cue that
             brings them up at a particular time. For instance, there can be an external trigger or
             an internal trigger.

             External triggers include something that you see, hear, touch, taste, or smell. Internal
             triggers include thoughts and feelings and memories.

             Whether the trigger is external or internal, it is something that reminds you of
             addictive, criminal or other destructive behaviors that you used to engage in,
             and which makes you feel like you want to engage in that behavior again.




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               Module 42 Handout: Triggers, Cravings, Urges
             Definitions

             • Cravings - desire to use alcohol or drugs, usually felt in the body
             • Urges - feelings and thoughts associated with wanting to do something
               destructive
             • Triggers - things that remind you of old destructive behaviors and bring up
               cravings and urges

                                        Types of Cravings and Urges

             • Substance Abuse related - feeling an impulse to get high or drink alcohol

             • Criminal - feeling an impulse to engage in criminal behaviors

             • Other Destructive Behaviors - wanting to stop medications for mental
               disorders, wanting to stop counseling, wanting to have unprotected sex, etc.

                                      Types of Triggers and Examples

             • External Triggers - from our external environment or situation; come through
               our 5 senses, something that reminds us of our old destructive behavior

                   Sight - driving past a bar, past the old neighborhood where you used to use
                    or commit crimes, the sight of others using or high, drug paraphernalia
                    (pipes, bottles, needles, etc.)

                   Smell - smelling alcohol or drugs, marijuana smoke, smell of old
                    neighborhood or bar

                   Hearing - the sound of a beer bottle opening, the sound of a drug or crime
                   associate’s voice on the phone, the sounds of people at a party, certain music you
                   used to listen to when you got high, someone telling a “war story” about
                   drugs/crimes

                   Taste - taste of a food or drink that you used to have when getting high or
                    drunk, such as coffee, a certain soda, or “munchies” food


                   Touch - the feeling of hugging someone you used to get high and have sex
                    with, the feeling of touching something that is like drug paraphernalia
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                    (pipes, bottles, needles, etc.)



               Module 42 Handout: Triggers, Cravings, Urges


             • Internal Triggers

                   Thoughts - remembering what it used to feel like to use, “glorifying” the old
                    days, only thinking about the pleasurable part of substance abuse, wishing
                    you could escape from everyday pressures, thinking “it’s not fair that I can’t
                    use, all of my old friends do”, rationalizing - “one won’t hurt”,
                    overconfidence - “I can handle it this time”, “I’m over this”, etc.

                   Feelings - negative feelings that you used to react to by using, such as
                   sadness, loneliness, depression, boredom, anger, anxiety or fear, stress,
                   shame, guilt, feeling bad about yourself, etc. Wanting some “excitement”, like
                   the rush you might have felt when performing a crime. Feelings
                   brought up by a drug or crime dream. Positive feelings and wanting to
                   “celebrate” them by using. Feelings brought up by social pressure or
                   conflict in relationships.




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                                          Module 42 Main Points



      Cravings = desire to use alcohol or drugs, usually felt in the body

      Urges = feelings and thoughts associated with wanting to do something destructive

      Triggers = things that remind you of old destructive behaviors and bring up cravings and urges

      External triggers are things outside of you that trigger you-sounds, sights, smells, tastes and touches

      Internal triggers occur inside you- thoughts and feelings




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                                                MODULE 43

                               Managing Triggers, Cravings, and Urges


               OBJECTIVES: 1. To help participants identify coping skills and strategies to manage cravings
              and urges when they arise. 2. To help them begin to practice these skills and begin to choose
              which ones work best for them.

             CONTENT: This session helps participants develop coping strategies and skills to
             manage cravings and urges.

             Say In Your Own Words:

             The topic for this group is Managing Cravings and Urges. In our last session, we
             identified different types of triggers, cravings, and urges, and now we are going to
             focus on coping with them.

                    Point out “Coping with Cravings and Urges” Handout and review with the
                     group.

                    Ask participants to add on to this sheet by circling those coping strategies
                    that work well for them and/or writing in their own under “others”.

                    Facilitate group discussion with people giving examples of what has
                    worked for them in the past, what hasn’t worked for them.

                    Get people to share as much as possible.

                    Give the homework of practicing these to find out which ones work best for
                    each person and keep using them).


             These pages could be useful to you to keep with you in your wallet after
             release, to remind you what to do instead of giving in to urges or cravings.




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               Module 43 Handout: Coping with Triggers, Cravings and Urges


             Remember: the first line of defense against cravings and urges is avoiding the
             triggers and high risk situations that give rise to them! Don’t go into that old
             neighborhood where you used to use or commit crimes, avoid bars, don’t keep any
             alcohol or drug paraphernalia around you, avoid interacting with people who are
             still using, don’t go to parties where people use, etc.

             Even if you do your best to avoid external triggers, some cravings and urges will
             still arise. Do your best to avoid your triggers, but be prepared to come across
             unexpected triggers. Even if you avoid all external triggers, you can still have
             internal triggers, such as thoughts, feelings, or memories, that can bring up
             cravings and urges.

             Cravings and urges are a normal part of recovery. Everyone in recovery
             experiences these at times. You don’t need to feel bad about yourself or your
             recovery just because you have a craving or urge. The important thing is to be
             aware of them and decide on an active coping strategy so that you can stop
             yourself from giving in to them.

             Cravings and urges grow weaker the longer you “starve” them. Giving in to them
             makes them stronger! Over time, as you maintain your recovery,
             cravings and urges will continue to get less and less, as long as you don’t give in to
             them. Giving in to cravings and urges may decrease the unpleasant
             sensations associated with them for a short time, but giving in to them only makes
             them stronger the next time!

             Coping Strategies: What to do when Cravings and Urges Arise

             Try out different coping strategies from the list below and see what works best
             for you. Practice them ahead of time so that you are prepared and know what
             to do when an urge does arise. When an urge does arise, keep trying different
             ones until one works, you may need to use different ones at different times.
             Underline those that work best for you, and write out others that work well
             for you that are not on this list (on bottom of second page, or on back of page).
             After release, keep these two pages with you in your wallet to refer to in an
             emergency.




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               Module 43 Handout: Coping with Triggers, Cravings and Urges

             Distraction - Do something else that is not a trigger, such as reading, exercise,
             take a shower, hobbies or sports, take a fast 10 min walk (only in a non-
             trigger neighborhood!) watching TV (be careful of beer commercials or
             shows/movies that glamorize drug or alcohol use or crime, maybe only watch
             PBS).

             Talking - Call or talk to a trusted friend who is a positive person and does not
             use or commit crimes, or call a counselor or sponsor. Ask for help. Talking
             about your urge may help you to get over it. Ask the person to let you talk about
             your reasons for not giving in to the urge, and ask them to remind you of the
             consequences of your behavior.

             Consequences - Remind yourself of your reasons for not giving in, and the
             good consequences of not giving in (staying out of incarceration, feeling good
             about yourself, making the urge get weaker the next time, etc.), as well as the
             possible bad consequences of giving in (incarceration, death, making the urge
             stronger next time, could lead to full relapse).

             Substitution - Instead of giving in to the urge, substitute a pleasant activity that
             is not harmful and is not one of your triggers, such as receiving a
             massage, giving yourself a massage, eating or drinking something you enjoy,
             chew gum, hard candy, etc.

             Wait it out - Remember that most cravings and urges only last for a few
             minutes, and simply wait it out.

             Urge Surfing - Use “urge surfing” by watching the urge and noticing it, and
             detaching yourself from it by realizing that it is not you, you don’t have to act on
             it, and it will decrease soon.

             Remove yourself from the situation that brought on the craving; leave the
             party or neighborhood, retreat to a safe drug free place. One way to do this
             temporarily in work or social situations is to excuse yourself to go to the
             bathroom.

             Self talk - Tell yourself positive messages, “This will be over soon”; “I can do
             this”, “I can get help if I need it”; “I don’t have to give in to this”, etc.

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             Get Angry and Fight with Your Urge - Fight against the urge like the enemy it is,
             and tell it; “Go to hell, I won’t let you trick me into hurting myself and ruining
             my life anymore” or similar statements.


               Module 43 Handout: Coping with Triggers, Cravings and Urges


             Support Groups - Go to a 12-step meeting or other support group. Being with
             others in recovery can help you to remember that you can get through this. Get
             other people’s names and numbers to call in case of future cravings and urges.
             Keep trying to get a positive person to be a temporary sponsor, and try to
             eventually get a long-term sponsor. Develop a positive social network of people to
             spend time with that don’t use or commit crimes.

             Breathe - Take 10 - 20 slow, deep breaths; the urge may be gone after only a few
             minutes of this. If it is not, then keep going with breathing and use urge surfing,
             meditation, prayer, visualization, or positive self - talk; whatever
             works for you!

             Meditation - meditating regularly will make that a pleasant, positive addiction and
             give you a natural, beneficial “high”. Then when you have an urge, you can
             meditate instead of using.

             Visualize the positive consequences of not giving in to the urge and the
             negative consequences of giving in to the urge. See what it would be like to be
             rearrested, feel how you would feel having to go back to prison. Now visualize how
             much stronger you will feel if you don’t give in to the urge, and how you will be
             happier in the long run.

             Pray - ask for help from your Higher Power.

             Reward yourself with something pleasant and not harmful when you have
             successfully resisted the urge. Give yourself some praise, and tell yourself
             “Good Job!”

             Others - write out other specific coping strategies not in this list, especially
             ones that work well for you (such as what kind of exercise, sports, reading,
             food, or hobbies help). You can also use the bottom of this page for this.




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                                         Module 43 Main Points



      Cravings and urges are a natural part of recovery.

      The more that you starve, the weaker they become.

      There are many different coping mechanisms to deal with urges and cravings. You may have to try
      several to find out what works best for you.

      You want to have several different coping mechanisms in your “toolbox” because you may not
      always be able to use your first choice.




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                                                 MODULE 44

                                             Lapse and Relapse


              OBJECTIVES: 1. To help participants learn more about the Abstinence Violation Effect.
             2. To help participants develop an emergency plan to cope with a lapse and
             keep it from becoming a full-blown relapse.

             CONTENT: This session helps participants learn more about the Abstinence
             Violation Effect, and helps them develop an emergency plan to cope with a lapse.

             Say In Your Own Words:

             In today’s group we will learn more about the Abstinence Violation Effect, which is
             an important part of the relapse prevention model. Does anyone remember what it
             is?

                    Solicit answers, and then go on to describe.

             So the Abstinence Violation Effect (A.V.E.) is a wrong belief, that if we make one
             mistake, then we have screwed up completely. So if we have a slip, or a lapse, and use
             drugs or alcohol one time, if we believe in the Abstinence Violation Effect, we will
             think we have completely blown our abstinence from drugs and alcohol, and that we
             will automatically go back to a full blown relapse.

             This belief is not true! If we quickly realize our mistake, and put into action our
             emergency plan to cope with a lapse, then we can get right back to recovery and
             abstinence, and prevent a full-blown relapse to our addiction. We will develop the
             emergency plan to cope with a lapse in this group.

             The same is true of mental illness and criminal behavior. For example, if we
             have one slip and we commit a petty crime, that does not mean that we automatically
             have to relapse to a full-blown criminal lifestyle. We can stop our criminal behavior
             and get back on track with abstaining from criminal behavior.

             The same is also true of mental illness; suppose one day we miss our depression medication,
             or our counseling, and our depression gets worse that day. That does not mean that we
             automatically are going to relapse to full-blown depression. Instead, we get ourselves back on
             track with our mental health medication and counseling as quickly as we can.


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             So the A.V.E. means that we have to learn ahead of time that if we have a lapse, we don’t have to
             feel totally guilty and angry at ourselves, because that will only contribute to a full blown relapse.
             Instead, we remember that a lapse is simply a mistake, and that we can quickly stop it from
             becoming a full-blown relapse by getting help and putting our emergency plan into action.

             The A.V.E. does not mean that we are suggesting that engaging in substance abuse,
             criminal behavior, or neglecting your mental health needs are safe activities with no
             consequences. On the contrary, these are dangerous, high risk behaviors that could lead
             to a full blown relapse. The best way to prevent a relapse is not to lapse at all.

             But we are all human, and all of us make mistakes at one time or another. The reason to learn
             about the A.V.E. is not to give ourselves permission, or an excuse, to lapse. The reason we learn
             about the A.V.E. is because we are human, and therefore we make mistakes.

             Learning about the A.V.E. helps us be prepared and plan how to cope with a
             mistake in a positive way that gets us back on track as soon as possible. We
             will now spend time on developing an emergency plan for coping with a lapse.



                    Point out handout “What to do if I Lapse; Emergency Plan”

                    Help the group brainstorm different ways to prevent a lapse from becoming a relapse,
                    and different ideas of how to answer the questions on the handout.

                    Have participants fill out each part, and share their answers with the
                     group.

                    If individuals get stuck, involve the group in helping them come up with
                     ideas.




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               Module 44 Handout: What to do if I Lapse-Emergency Plan


             Keep this handout with you in case of an emergency!

             So you have lapsed; that means that you have had a slip into a small episode
             of substance use, or criminal behavior, or have been neglecting your mental
             health needs which has caused your mental illness symptoms to increase.

             Steps I will take to prevent a full-blown relapse
             Remember not to let yourself be tricked by the Abstinence Violation Effect.
             The Abstinence Violation Effect is a mistaken belief that once you have had a
             lapse, you are automatically going to return to a full-blown relapse. This
             mistaken belief can lead to feelings of guilt, anger at oneself, or giving up, and
             can lead to a full-blown relapse. Instead, forgive yourself and get back on
             track as soon as possible by following your plan below. Learn from your
             lapse.


             First, identify which kind of lapse you have had: a Substance Lapse, a Criminal
             Lapse, or a Mental Health Lapse; it could be more than one; then follow the
             coping steps listed under those kinds of lapses.




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               Module 44 Handout: What to do if I Lapse-Emergency Plan
             Substance Lapse
             1) I will remove myself from any high-risk situations as quickly as possible and get to a safe
                place.

             2) I will keep calling people from my recovery network until I find someone who can help me
                get back on track.

                            Names and numbers of 3 people to call if I have this type of lapse

                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________


             3) Other specific steps I can take to keep this from becoming a full-blown relapse.

             Criminal Lapse
             1) I will remove myself from any high-risk situations as quickly as possible and get to a safe
             place.

             2) I will keep calling people from my recovery network until I find someone who can help me
                get back on track.

                            Names and numbers of 3 people to call if I have this type of lapse

                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________

             3) Other specific steps I can take to keep this from becoming a full-blown relapse.


             Mental Health Lapse

             1) I will remove myself from any high-risk situations as quickly as possible and get to a safe
                 place. This might mean taking myself to a hospital Emergency Room for medication and
                 stabilization.
             2) I will keep calling people from my recovery network until I find someone who can help me
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                 get back on track.

                            Names and numbers of 3 people to call if I have this type of lapse

                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________

             3) Other specific steps I can take to keep this from becoming a full-blown relapse.


               Module 44 Handout: What to do if I Lapse-Emergency Plan


             Questions to answer when developing your emergency plan:

             1) What is a safe place for me to go to? (It should be in a place where no one does drugs or
                commits crimes, and not one of my high-risk situations or triggers. Maybe it is a 12-step or
                other support group.)_________________________________________________________



             2) What mental illness or substance abuse symptoms are signals that I should go to the hospital
              emergency room?____________________________________________________________




             3) Is there some way I can undo whatever criminal behavior I have committed? Who can best
                help me to overcome what I have done and get back on track?_________________________



             4) How can I overcome the Abstinence Violation Effect, and not fall into the mistake that I have
                to have a full-blown relapse? __________________________________________________



             5) How can I forgive myself quickly so that guilt, anger, depression or other strong emotions
                don’t contribute to me having a full-blown relapse?_________________________________



             6) Other coping ideas___________________________________________________________




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                                           Module 44 Main Points



      Both lapses and relapse can occur in recovery.

       A lapse is when you have had a slip into a small episode of substance use, or criminal behavior,or
      have been neglecting your mental health needs which has caused your mental illness symptoms to
      increase.

      A relapse is when you let the one small mistake completely derail you off the healthy lifestyle track.

      Though it is best to not have either, don’t turn a lapse into a full relapse.

      The Abstinence Volitional Effect (AVE) is a mistaken belief that once you have had a
      lapse, you are automatically going to return to a full-blown relapse. This is not true, unless you
      make the choice to make it true.

      BUT- your ultimate goal should be to have neither lapses nor relapses. Lapses are very dangerous
      territory to be in. If you do lapse, immediately reach out to your support system.




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                                                 MODULE 45

                                              Recovery Networks


               OBJECTIVES: 1. To help participants understand the importance of a recovery network.
               2. To help participants begin to strategize how to develop a recovery network
              and plan who could be in it.

             CONTENT: This session emphasizes the importance of a recovery network and helps
             participants begin to strategize how to develop a recovery network and plan who could be in it.



             Say In Your Own Words:

             Today's topic is developing a recovery network. In order to keep from
             relapsing into substance abuse, mental illness, or criminal behavior, people need to
             develop a recovery network. In the past, when you engaged in
             criminal and substance abuse behavior, or let your mental illness get out of control,
             what kinds of people did you tend to hang out with?

                    Solicit examples of people that were not good for them to spend time with
                    and kept them stuck in substance abuse, criminal behavior, etc.

             There is a lot of scientific research that shows that we tend to act, talk, think, and
             pick up the attitudes of those we spend time with. So you need to be careful who
             you spend time around.

             If you want to recover from substance abuse, mental illness, and criminal behavior, you need to
             develop a recovery network of positive people who don’t use substances or commit crimes, and
             who can help you to maintain your recovery in these areas, including mental health.

             We become like the people that we hang out with, so you can’t go back to spending time with
             your old substance abuse or criminal network, or you will sooner or later relapse. No one is
             totally independent, and we all need help, and so you can’t just go out there deciding not to hang
             around your old crowd, you have to actively develop a new network of people to replace your
             old one.

             This new group will be your recovery network, and it will be especially
             important for you when you are released, or go back into the general

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             population. Perhaps you can already begin developing it to some degree now with
             phone contacts.

             What are the major areas of your life that you can develop a recovery network
             in?

                    Solicit examples.

                    Give out handout, “Developing a Recovery Network” review it with the
                    group, and have participants fill it out.

                    Encourage participants to discuss it as a group to get help and ideas from
                    each other.




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             Module 45 Handout: Developing a Recovery Network


             Who should be in my Recovery Network? Add in names of people who could
             be helpful to you in recovery in as many categories below as possible.
             Remember to only choose people who do not use alcohol or drugs, do not
             engage in criminal behavior, and will be helpful and supportive of you in your
             recovery from substance abuse, criminal behavior, and mental illness.

              People from 12-step and other support groups:


              People where you live or near where you live:


              Treatment professionals (counselors, case managers, doctors, etc.):


              Criminal Justice professionals (such as probation or parole officers, or case managers):


              People from church or other spiritual organizations:


              Family:


              Friends:


             Who is missing from the above list that should be here?


             What steps could you take to get these people involved in your recovery?


             What should you tell the above people to educate them about your recovery?


             How can you ask them to assist you in recovery?



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             Hint: One good strategy is to attend 12-step and other support groups regularly and get names and phone numbers of
             people on a regular basis who you think could be helpful to your recovery. Ask for a temporary recovery sponsor ASAP
             and then get a long term one.




                                                   Module 45 Main Points



      Your social and personal relationships can make or break your recovery.

      Healthy, clean and sober, pro-social people will help it.

      Unhealthy people will harm it.

      It is critical to develop a good support system.

      There is an old proverb that says, “Show me who your friends are, and I will show you who you are.”




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                                              MODULE 46
                                         Relapse Prevention Plan


            You will be developing a comprehensive relapse prevention plan. This plan is designed to
            give you an overall picture of where you want to go with your life in order to maintain your
            recovery and not relapse into substance abuse, mental illness, or criminal behavior. This plan
            will be summary of your work from previous groups, use your handouts to assist you in
            completing it.

                     Group participants should work on this plan before attending group and
                 then verbally process it in a group setting. Group members should be encouraged
                 to appropriately “challenge’ each other if plans are incomplete or unrealistic.

                    The plans should cover relapse into substance abuse, mental illness and criminal
                    behavior.




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                                          RELAPSE PREVENTION PLAN


                  Goals, Time Management, and Lifestyle Balance

                    a) What are my life goals that will help me maintain my recovery after release?
                       What steps am I going to take to work toward achieving my goals?




                    b) How do I plan to live a balanced lifestyle to maintain my recovery? What areas of
                       my life do I want to balance?




                    c) How do I plan to manage my time after my release? What daily/weekly activities
                       am I going to do to maintain my recovery, and how often?




                 Coping with Stress-What positive activities will I do to cope with stress?




                 My past Seemingly Irrelevant Decisions that could set me up for relapse,
                 and how to avoid them in the future:




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                                            RELAPSE PREVENTION PLAN



                 Early Warning Signs
                    a) My early warning signs for relapse into substance abuse:




                    b) What will I do to avoid relapse when I notice these warning signs?




                    c) My early warning signs for relapse into mental illness:




                    d) What will I do to avoid relapse when I notice these warning signs?




                    e) My early warning signs for relapse into criminal behavior:




                    f) What will I do to avoid relapse when I notice these warning signs?




                 Managing Cravings and Urges

                    a) What things trigger my cravings/urges to relapse or commit crimes? How can I
                       avoid those triggers?




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                    b) Which techniques work best for me to manage my cravings/urges when they
                       arise?




                                           RELAPSE PREVENTION PLAN



                 My Emergency Plan to prevent a lapse from becoming a full-blown relapse?




                 Coping with high-risk situations for relapse into substance abuse or criminal acts:

                    a) What are my personal high-risk situations for relapse? How do I plan to avoid
                       them and cope with them?




                    b) How do I plan to cope with Feeling Bad so that I do not relapse?




                    c) How do I plan to resist Social Pressure to use drugs/alcohol or commit crimes




                    d) Coping with Conflict:

                       i) How do I plan to change my thinking to cope with conflict and not relapse?




                       ii) How do I plan to communicate more effectively to cope with conflict?


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                                            RELAPSE PREVENTION PLAN


                  Avoiding Future Incarceration

                    a) Errors in Thinking



                       i) My main thinking errors that led to me committing crimes & going to prison:




                       ii) My main positive thoughts with which I will replace my thinking errors:




                    b) What will I do differently to make sure I don’t go back to prison?




                 How do I plan to maintain treatment for my mental health, substance
                 abuse, and physical health needs after release?




                 What is my housing plan for after I am released?




                  What is my employment plan for after I am released?

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                 How do I plan to develop a recovery network after I am released?




                                          Module 46 Main Points



      A well thought out and complete Relapse Prevention Plan is critical to your recovery.

      You should share your plan with the important people in your life- spouse, parents, parole officer, etc..

      A Relapse Prevention Plan needs to be revisited and modified on a regular basis.




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                                                MODULE 47
                                     Benefits of Leading a Healthy Life

                 General Introduction
                 Individuals with co-occurring disorders often have low perceived self-efficacy; that is, the
                 belief or expectancy that they will not be effective in work, life, and play in the free world.
                 Research has demonstrated that self-efficacy plays a strong role in determining whether or not
                 certain tasks will be attempted, and then determines how long people will persist in the face
                 of obstacles. Persons with low self-efficacy avoid situations that they believe exceed their
                 capabilities and give up easily when they encounter difficulties. This perception is actually
                 more predictive of successful achievement than a person’s actual capabilities. Hence, self-
                 efficacy is directly related to maintaining motivation. The next four modules are designed
                 to help clarify the participants’ motivation to be successful in the free world. It helps them
                 clarify their values, develop short and long term goals, and then works with their inner
                 perceptions of self-efficacy and self-esteem to help them believe that their futures can be real.
                 Exercises are designed to develop expectancies for a successful future and to overcome old
                 scripts and external constraints that have been barriers to successful achievements. This unit
                 attempts to build self-confidence, persistence, and resilience into the participants’ self-
                 image.

                 Rationale

                 Most motivational programs work by exhorting people to “visualize success.” A history of
                 poor performance leads people to expect and even visualize failure. This then leads to a poor
                 self-image and perceptions a low self-efficacy. Research suggests that guided imagery can be
                 an effective tool in restructuring the self-image and thereby increasing self-efficacy and the
                 motivation to be successful. Golfers visualize and rehearse a successful shot before they hit it.
                 Boxers visualize completing their boxing moves and winning the fight before they enter the
                 ring. And, students sustain the motivation to complete grueling curricula by visualizing
                 themselves as successful doctors, lawyers, psychologists and the like. Working with the
                 participants present motivation and strengths and skills, guided imagery is employed to
                 attempt to “make futures real,” to increase self-efficacy about being successful in the free
                 world, and to learn how to persist in the face of obstacles.


                 CONTENT: Engaging in any behavior has certain advantages or benefits and
                 certain costs. The purpose of this session is to review and update the participants’
                 understanding of the costs and benefits of substance abuse, criminal behavior, and


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                 neglecting mental health needs. After these analyses, are the participants willing
                 to make a commitment to being abstinent, going straight, and being mentally
                 healthy?

                 Say in Your Own Words:

                 This group is about maintaining your motivation to be abstinent, straight, and mentally
                 healthy. Motivation to do anything waxes and wanes. Things happen to interfere with our
                 motivation, and other groups in this series will be dealing with those factors. However, it is
                 also important to not lose sight of your goals and to remember what is the ultimate purpose
                 of going through this program. That will be the focus of this series. We will be helping you
                 keep focused on your goals, help you see yourself as being successful in reaching and
                 maintaining your goals, and help you to experience the rewards of being successful.
                 Being abstinent, going straight, being mentally healthy, what do you want that for? In other
                 words, what is the payoff to you in doing those behaviors? The first step in maintaining
                 motivation is understanding the payoffs for our behavior. We first want you to update your
                 payoff matrices so that you understand the cost and benefits associated with
                 behavior.

                    Hand out the Payoff Matrix definition sheet and three Payoff matrices,
                    one for each of the behaviors of substance abuse, criminal behavior, and
                     mental health.

                    The group leader will likely have to go around and prompt the participants
                    because they are likely to say that there are no benefits to abusing substances
                    or doing crimes. Of course there are benefits or they wouldn’t do them or
                    be at risk for relapse. After they complete the task, have the group members
                    share their Payoff Matrices. The group leader should attempt to get an oral
                    and/or a written agreement from the participants to stay abstinent, go
                    straight, and be mentally healthy.




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             Module 47 Handout: Payoff Matrix-- Directions


                               Advantages/Benefits               Advantages/Benefits
                            What are the benefits/payoffs        What are the benefits/
                            of using drugs and alcohol?        payoffs of being clean and
                            What do you gain by using?        sober? What do you gain by
                                                                       not using?




                             Disadvantages/ Losses             Disadvantages/ Losses
                                   What are the                What are the negatives/
                            negatives/downside of using       downside of staying clean
                            drugs and alcohol? What do       and sober? What do you lose
                                you lose by using?                  by not using?




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                 Module 47 Handout: Payoff Matrix Substance Abuse


                 The Behavior: Using drugs and alcohol.

                                Advantages/Benefits           Advantages/Benefits
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15
                               Disadvantages/ Losses         Disadvantages/ Losses
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15




Attachment #8                                          365
Solicitation No. 110068DC
                 Module 47 Handout: Payoff Matrix Mental Illness


                 The Behavior: Not following my treatment plan- not attending counseling or taking
                 medications.

                                Advantages/Benefits           Advantages/Benefits
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15
                               Disadvantages/ Losses         Disadvantages/ Losses
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15




Attachment #8                                          366
Solicitation No. 110068DC
                 Module 47 Handout: Payoff Matrix Criminal Thinking


                 The Behavior: Breaking the law/ not following rules to get my “needs” met.

                                Advantages/Benefits           Advantages/Benefits
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15
                               Disadvantages/ Losses         Disadvantages/ Losses
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15




Attachment #8                                          367
Solicitation No. 110068DC
                                         Module 47 Main Points



      Before you engage in a behavior or make a decision, you should weigh the positives and negatives.

      It is important to be honest about both or you might artificially “weight” your decision.

      It is vital that you acknowledge that there are some positives to drug use, criminal behavior and
      mental illness. By acknowledging the “good” parts you can figure out ways to achieve these without
      the negatives associated with relapse. For instance, if you like the fact that substance abuse reduces
      you stress (in the moment) then you can find other, healthy and long term ways to reduce your stress.
      Ways that do not also include negatives.




Attachment #8                                         368
Solicitation No. 110068DC
Attachment #8               369
Solicitation No. 110068DC
                                                  MODULE 48
                                               Values Clarification


                OBJECTIVES: 1. To re-acquaint the participants with personal values. 2. To help the
               participants to clarify and prioritize personal values.

                 CONTENT: This session is concerned with helping the participants clarify their
                 personal values. After completing and scoring the Forced Choice Values Test, the
                 participants should have a good idea of what is important to them.
                 Understanding values will help the participants prioritize their short and long
                 term goals following release.

                 Say in Your Own Words:

                 We will begin this session by completing the Forced Choice Values Test. You
                 may have completed the Test before. However, it is important to update your
                 understanding of what is important to you. In other words, values motivate us
                 toward certain goals so it is important to be clear about our values.

                            Administer the Forced Choice Values Test to the participants and then
                            teach them how to score it. At the end they should have a rank
                            ordering of their values from most to least important. Also hand out
                            the List of Values Sheet. Have the participants add any additional
                            values that they find important. They can choose to substitute one or
                            more values from the List in place of the Forced Choice Values. Then,
                            have each participant share their three most important values. They
                            should relate why those values are so important to them and how
                            substance abuse, criminal behavior, and mental illness have affected
                            their ability to live according to those values.




Attachment #8                                            370
Solicitation No. 110068DC
                 Module 48 Handout: Values Clarification Survey



                 DIRECTIONS: Circle the number preceding one of the two choices in each category. You
                 must choose one number in each pair of items.

                 1      To be reasonably sure about the future for my family and myself.

                 12    To do things well.
                 ______________________________________________________________________

                 3      To have people think well of me.

                 5     To have as much freedom as possible to do the things I want to do.
                 ______________________________________________________________________

                 11     To have as many good things as possible.

                 12    To do things well.
                 ______________________________________________________________________

                 6      To do new and different things often.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 7      To have friends.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 6      To do new and different things often.

                 8     To create an atmosphere that makes for satisfying family living.
                 ______________________________________________________________________

                 3      To have people think well of me.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________




Attachment #8                                               371
Solicitation No. 110068DC
                 Module 48 Handout: Values Clarification Survey

                 8     To create an atmosphere that makes for satisfying family living.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 10    To have things neat, orderly and organized.

                 12    To do things well.
                 ______________________________________________________________________

                 2     To have influence with people.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 2     To have influence with people.

                 12    To do things well.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 12    To do things well.
                 _____________________________________________________________________

                 4     To do things for my family and others.

                 7     To have friends.
                 ______________________________________________________________________

                 5     To have as much freedom as possible to do things that I want to do.
Attachment #8                                              372
Solicitation No. 110068DC
                 8     To create an atmosphere that makes for satisfying family living.
                 ______________________________________________________________________




                 Module 48 Handout: Values Clarification Survey


                 2     To have influence with people.

                 3     To have people think well of me.
                 ______________________________________________________________________

                 7     To have friends.

                 8     To create an atmosphere that makes for satisfying family living.
                 _____________________________________________________________________

                 5     To have as much freedom as possible to do the things I want to do

                 12    To do things well.
                 ______________________________________________________________________

                 3     To have people think well of me.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 6     To do new and different things often.

                 12    To do things well.
                 ____________________________________________________________________

                 9     To do what is right according to my beliefs.

                 12    To do things well.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 3     To have people think well of me.

                 8     To create an atmosphere that makes for satisfying family living.
                 ______________________________________________________________________


Attachment #8                                              373
Solicitation No. 110068DC
                 Module 48 Handout: Values Clarification Survey

                 5     To have as much freedom as possible to do things I want to do.

                 6     To do new and different things often.
                 ______________________________________________________________________

                 6     To do new and different things often.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 5     To have as much freedom as possible to do things I want to do.
                 ______________________________________________________________________

                 3     To have people think well of me.

                 6     To do new and different things often.
                 ______________________________________________________________________

                 5     To have as much freedom as possible to do things I want to do.

                 7     To have friends.
                 ______________________________________________________________________

                 10    To have things neat, orderly and organized.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 2     To have influence with people.

                 4     To do things for my family and others.
                 ______________________________________________________________________

                 8     To create an atmosphere that makes for satisfying family living.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

Attachment #8                                              374
Solicitation No. 110068DC
                 8     To create an atmosphere that makes for satisfying family living.
                 12    To do things well.
                  ______________________________________________________________________




                 Module 48 Handout: Values Clarification Survey

                 4     To do things for my family and others.

                 5     To have as much freedom as possible to do things I want to do.
                 ______________________________________________________________________

                 9     To do what is right according to my beliefs.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 2     To have influence with people.
                 ______________________________________________________________________

                 9     To do what is right according to my beliefs.

                 10    To have things neat, orderly and organized.

                 ______________________________________________________________________
                 6     To do new and different things often.

                 7     To have friends.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 6     To do new and different things often.
                 ______________________________________________________________________

                 2     To have influence with people.

                 5     To have as much freedom as possible to dot things I want to do.
                 ______________________________________________________________________

                 4     To do things for my family and others.

Attachment #8                                              375
Solicitation No. 110068DC
                 8     To create an atmosphere that makes for satisfying family living.
                 ______________________________________________________________________




                 Module 48 Handout: Values Clarification Survey

                 3     To have people think well of me.

                 7     To have friends.
                 ______________________________________________________________________

                 6     To do new and different things often.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

                 7     To have friends.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 2     To have influence with people.

                 7     To have friends.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

                 5     To have as much freedom as possible to do things I want to do.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 4     To do things for my family and others.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

Attachment #8                                              376
Solicitation No. 110068DC
                 7     To have friends.
                 ______________________________________________________________________

                 3     To have people think well of me.

                 12    To do things well.
                 ______________________________________________________________________




                 Module 48 Handout: Values Clarification Survey

                 1     To be reasonably sure about the future for my family and myself.

                 3     To have people think well of me.
                 ______________________________________________________________________

                 5     To have as much freedom as possible to do things I want to do.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

                 7     To have friends.

                 12    To do things well.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 6     To do new and different things.
                 ______________________________________________________________________

                 2     To have influence over people.

                 6     To do new and different things.
                 ______________________________________________________________________

                 7     To have friends

                 9     To do right according to my beliefs
                 ______________________________________________________________________

                 3     To have people think well of me
Attachment #8                                              377
Solicitation No. 110068DC
                 10    To have things neat, orderly and organized
                 ______________________________________________________________________

                 2     To have influence over people

                 8     To create an atmosphere that makes for satisfying family living
                 _____________________________________________________________________




                 Module 48 Handout: Values Clarification Survey

                 1     To be reasonably sure about the future for my family and myself.

                 8     To create an atmosphere that makes for satisfying family living.
                 _____________________________________________________________________

                 2     To have influence over people

                 9     To do right according to my beliefs
                 _____________________________________________________________________

                 5     To have as much freedom as possible to do the things that I want to do.

                 10    To have things neat, orderly and organized.
                 _____________________________________________________________________

                 8     To create an atmosphere that makes for satisfying family living.

                 11    To have as many good things as possible.
                 _____________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 11    To have as many good things as possible.
                 _____________________________________________________________________

                 2     To have influence with people

                 10    To have things neat, orderly and organized.
                 _____________________________________________________________________

                 3     To have people think well of me.

                 4     To do things for my family and others.
                 _____________________________________________________________________

Attachment #8                                              378
Solicitation No. 110068DC
                                       Module 48 Handout: Values Clarification Survey


                                                   FORCED VALUES TALLY SHEET



                                                                Number of times chosen
                                                    1   2   3   4 5 6 7 8 9 10           11   12
                                                                                                   Represents
                                           1                                                       SECURITY
        Number with chosen statement




                                           2                                                       INFLUENCE
                                           3                                                       RECOGNITION
                                           4                                                       HELPFULNESS
                                           5                                                       FREEDOM
                                           6                                                       NEW EXPERIENCE
                                           7                                                       FRIENDLINESS
                                           8                                                       FAMILY LIFE
                                           9                                                       MORAL STANDARDS
                                          10                                                       ORDERLINESS
                                          11                                                       WEALTH
                                          12                                                       WORKMANSHIP




Attachment #8                                                            379
Solicitation No. 110068DC
                 Module 48 Handout: Values Clarification Survey

                                 KEY TO FORCED CHOICE VALUES TEST
                 Directions:

                        1.      Look back on the test and count the number of times you circled each
                                number. You can use the Tally Sheet to help with this. Record the amount
                                to the left of each number on this key.
                        2.      Rank order those amounts to the right of the sentences corresponding
                                to the numbers. Rank the number with the greatest amount as
                                number 1.
                        3.      If a tie occurs, choose which quality is more important to you while
                                ranking.

                 No. of times
                 Circled                                     Rank        Key
                 __________1.                                __________ To be reasonably sure about
                 SECURITY                                                the future for my family and
                                                                         myself.

                 __________2.                                __________ To have influence with
                 INFLUENCE                                               people

                 __________3.                                __________ To have people think well of
                 RECOGNITION                                             me

                 __________4.                                __________ To do things for my family
                 HELPFULNESS                                            and others


                 __________5.                               __________ To have as much freedom as
                 FREEDOM                                                possible to do the things I
                                                                        want to do
Attachment #8                                              380
Solicitation No. 110068DC
                 __________6.                   __________ To do new and different
                 NEW EXPERIENCE                             things often

                 __________7.                   __________ To have friends
                 FRIENDLINESS

                 __________8.                   __________ To arrange for a family
                 FAMILY LIFE                                atmosphere that makes for
                                                            satisfying family living




                 Module 48 Handout: Values Clarification Survey

                                 KEY TO FORCED CHOICE VALUES TEST

                 __________9.                   __________ To do what is right according
                 MORAL STANDARDS                            to my beliefs


                 __________10.                   __________ To have things neat, orderly
                 ORDERLINESS                                 and organized

                 __________11.                   __________ To have as many good things
                 WEALTH                                      as possible

                 __________12.                   __________ To do things well.
                 WORKMANSHIP




                 What are your top 3 values?

                 1.

                 2.

                 3.




Attachment #8                                   381
Solicitation No. 110068DC
                 Module 48 Handout: Values- Things or Concepts You Might Value


                 LIST OF VALUES

                 Acceptance         to fit in with others

                 Accuracy           to be correct in my opinions and actions

                 Achievement        to accomplish and achieve

                 Adventure          to have new and exciting experiences

                 Attractiveness     to be physically attractive

                 Authority          to be in charge of others

                 Beauty             to appreciate the beauty around me

                 Caring             to take care of others

                 Comfort            to have a pleasant enjoyable life

                 Compassion         to feel concern for others

                 Complexity         to have a life full of variety and change

                 Contribution       to make a contribution that will endure

                 Courtesy           to be polite and considerate of others

Attachment #8                                     382
Solicitation No. 110068DC
                 Creativity              to have new and original ideas

                 Dependability           to be reliable and trustworthy

                 Ecology                 to live in harmony with the environment

                 Faithfulness            to be loyal and reliable in relationships

                 Fame                    to be known and recognized

                 Family                  to have a happy, loving family

                 Flexibility             to adjust to a new or unusual situation easily

                 Forgiveness             to be forgiving of others

                 Friends                to have close, supportive friends




                 Module 48 Handout: Values- Things or Concepts You Might Value

                 Fun             to play and have fun

                 Generosity      to give what I have to others

                 God’s will      to seek and obey the will of God

                 Growth          to keep changing and growing

                 Health          to be physically fit and healthy

                 Helpfulness     to be helpful to others

                 Honesty         to be truthful and genuine

                 Hope            to maintain a positive and optimistic outlook

                 Humility        to be modest and unassuming

                 Humor           to se the humorous side of the world and myself

                 Independence    to be free from the dependence of others

                 Industry        to work hard and well at my life tasks

                 Inner Peace     to experience personal peace

                 Intimacy        to share my inner most feelings
Attachment #8                                        383
Solicitation No. 110068DC
                 Justice          to promote equal and fair treatment for all

                 Knowledge        to learn and possess valuable knowledge

                 Leisure          to take time to relax and enjoy

                 Logic            to live rationally and sensibly

                 Loved            to be loved by those close to me

                 Loving           to give love to others

                 Moderation       to avoid excesses and find a middle ground

                 Monogamy         to have one close, loving relationship

                 Orderliness      to have a life that is well-ordered and organized




                 Module 48 Handout: Values- Things or Concepts You Might Value

                 Pleasure         to feel good

                 Popularity       to be well-liked by many people

                 Power            to have control over others

                 Responsibility   to make and carry out important decisions

                 Realism          to see and act realistically and practically

                 Risk             to take risks and chances

                 Romance          to have an intense, exciting love relationship

                 Safety           to be safe and secure

                 Self-control     to be disciplined and govern my own actions

                 Self-esteem      to like myself just as I am

                 Self-knowledge   to have a deep, honest understanding of myself

                 Service          to be of service to others

                 Sexuality        to have an active and satisfying sex life

                 Simplicity       to live life simply, with minimal needs
Attachment #8                                              384
Solicitation No. 110068DC
                 Stability      to have a life that stays consistent

                 Strength       to be physically strong

                 Spirituality   to grow spiritually

                 Tolerance      to respect and accept those different from me

                 Tradition      to follow the patterns of the past

                 Virtue         to live a morally pure and excellent life

                 Wealth         to have plenty of money

                 World Peace    to work to promote peace in the world




Attachment #8                                         385
Solicitation No. 110068DC
                                          Module 48 Main Points



      There are many different things/ concepts that you can value.

      What you value may not be what someone else values.

      You have certain “key values” that define who you are

      Your values dictate your choices.




Attachment #8                                        386
Solicitation No. 110068DC
                                                MODULE 49
                                           Goals for the Next 5 Years


                 OBJECTIVES: 1. To emphasize the importance of life goals in achieving successful
                reintegration into the community. 2. To have participants identify their personal life goals
                over the next five years. 3. To examine the potential impact of relapse on achieving life
                goals.

                 CONTENT: The content of this session is to re-acquaint the participants
                 with their life goals, a strong motivating force to remain substance free, law
                 abiding, and mentally healthy.

                 Say in Your Own Words:

                 One of the strongest motivations we as humans have is the search for
                 meaning and life satisfaction. There are some areas of your life that need to
                 be managed well in order for you to achieve your goals and to experience
                 satisfaction.

                 When anyone who has struggled with relapse is asked, “Why do you
                 want to remain clean and sober, or mentally healthy, and/or stay out of jail?” they
                 usually cite one or more of their life goals. They say “ I love my family, I want to
                 do it for them.” Or, “I have so much potential, I want to be a photographer and
                 take beautiful pictures.” Others will cite spiritual goals such as being right with
                 the lord or social or parenting goals. Hence, life goals both guide and motivate us.

                 The experience of lack of meaning or goals has been cited as the one of the
                 reasons that people do relapse. “I am bored,” “I feel like I’m in a rut,” “There is
                 nothing to live for,” are things we hear before a person experiences a relapse
                 into substance abuse, criminal activity, or neglecting mental health needs.



                        The therapist should explain the LIFE Goals Worksheet for the
                     participants to complete.




Attachment #8                                            387
Solicitation No. 110068DC
                 The worksheet presents life goals for the areas of marriage and family,
                 school and work, social, spiritual, leisure time, emotional, and material goals
                 for the participants to complete and discuss. The therapist will need to
                 provide some guidance so that the goals are (1) realistic and achievable and
                 (2) are broken down into short, intermediate, and long term. For example, under
                 School and Work Goals the people should not go directly to
                 “obtaining my Ph.D. in physics.” Rather, a sequence of goals is appropriate such
                 as (1) obtain my GED, (2) attend a community college to achieve my associates
                 degree, (3) earn my B.S. in physics at Florida State, (4) work and attend graduate
                 school part time to earn masters degree in physics, and (5) complete my Ph.D. in
                 physics.

                 For marriage the goal should not be find a woman and get married. Rather,
                 goals such as (1) Meet a healthy member of the opposite sex, (2) begin a
                 dating relationship, (3) work on developing healthy intimacy and a healthy
                 relationship free of substances, and (4) explore the possibility of marriage.

                 The participants should do this process for each area. After goals have been
                 identified, lead a discussion of the some of the goals that participants did identify.
                 Have the participants start out with the statement, “Five years from now I’ll
                 be……………….”

                 Correct the participants if they use words like “I hope to be” or “If I’m
                 able.” The key phrase is “I will be.”




Attachment #8                                            388
Solicitation No. 110068DC
                 Module 49 Handout: My Five Year Plan


                 Imagine how you want your life to be five years from now with regard to work, play,
                 relationships with others, and your relationship to yourself. Now think of the small goals that
                 you will need to achieve to make these goals come true. For example, if you see
                 yourself working as a computer specialist five years from now, your goals might be (1)
                 Earn my GED, (2) Attend technical school to learn basic computer skills, (3) take a entry
                 level position to gain computer programming experience, and (4) work for a top
                 computer software company.


                 A. Marriage and/or Family Goals: How would you like to develop or strengthen your
                 relationships. Include sharing of activities and the development of closeness.

                    Major Five Year Goal:__________________________________________

                    Subgoals:

                    1. __________________________              2._________________________

                    3. __________________________              4. _________________________

                    5. __________________________              6. _________________________

                    7. __________________________              8. _________________________


                 B. School and Work Goals: What are your school, work, and job objectives both short
                    term and long term?

                    Major Five Year Goal:____________________________________________

                    Subgoals:

                    1. __________________________              2._________________________

                    3. __________________________              4. _________________________

                    5. __________________________              6. _________________________

                    7. __________________________             8. _________________________
Attachment #8                                                389
Solicitation No. 110068DC
                 Module 49 Handout: My Five Year Plan



                 C. Social and Friendship Goals: What are your goals with regard to friends and social
                    activities? What groups or clubs or other organization do you want to be part of?

                    Major Five Year Goal:________________________________________________

                    Subgoals:

                    1. __________________________          2._________________________

                    3. __________________________          4. _________________________

                    5. __________________________          6. _________________________

                    7. __________________________          8. _________________________


                 D. Leisure Time and Recreation Goals: What do you want to do with your free time.
                    What hobbies, sports, or interests do you want to develop?

                    Major Five Year Goal:_______________________________________________

                    Subgoals:

                    1. __________________________          2._________________________

                    3. __________________________          4. _________________________

                    5. __________________________          6. _________________________

                    7. __________________________          8. _________________________


                 E. Personal Development Goals: What new attributes do you want to develop in
                    yourself? Strengthen? Decrease?

                    Major Five Year Goal:___________________________________________

                    Subgoals:
Attachment #8                                            390
Solicitation No. 110068DC
                    1. __________________________    2._________________________

                    3. __________________________    4. _________________________

                    5. __________________________    6. _________________________

                    7. __________________________    8. _________________________




Attachment #8                                       391
Solicitation No. 110068DC
                 Module 49 Handout: My Five Year Plan


                 F. Spiritual Goals: What would you like to see happen with your spiritual life?


                    Major Five Year Goal:__________________________________________

                    Subgoals:

                    1. __________________________            2._________________________

                    3. __________________________            4. _________________________

                    5. __________________________            6. _________________________

                    7. __________________________            8. _________________________


                 G. Emotional Goals: What emotions do you want to handle better? What feelings do
                    you want to feel more? Feel Less?

                    Major Five Year Goal:______________________________________________

                    Subgoals:

                    1. __________________________            2._________________________

                    3. __________________________            4. _________________________

                    5. __________________________            6. _________________________

                    7. __________________________            8. _________________________




Attachment #8                                              392
Solicitation No. 110068DC
                                          Module 49 Main Points



      It is not enough to have goals for the next few months.

      You should have goals for at least the next five years.

       Goals give our life direction.

      Goals give our lives meaning.

      Break down “BIG” goals into smaller sub-goals so that it does not feel overwhelming.

      Make your goals challenging but realistic and attainable.




Attachment #8                                          393
Solicitation No. 110068DC
                                                   MODULE 50
                                             Envisioning Your Future


                                                      OBJECTIVE:
                 To engage participants in the “crystal ball” exercise in which they see themselves
                 experiencing the rewards of achieving their goals five years in the future.

                 CONTENT: The majority of this session is spent in a guided imagery exercise. After
                 becoming aware of their future life goals, the participants are instructed to gaze into a
                 “crystal ball” and see themselves five years in the future. In the guided imagery they have
                 achieved their five-year goals and are enjoying the rewards of doing so. Group discussion
                 follows the exercise.

                         Have the participants bring their Life Goals Worksheet to the
                      session. Have them quickly go over the Worksheet in order to become
                      clear about where they want to be five years after release from prison.

                 Say in Your Own Words:


                 Today, we’ll begin by having everyone review the Life Goals
                 Worksheet. In a minute we are going to do the “crystal ball” technique.
                 Many people that have been to prison, abused substances, or suffered
                 from psychological difficulties have a poor self-image. Although they
                 can say the words about succeeding on the outside, in their unconscious
                 mind they still see themselves as losers or incompetents. Deep down they
                 really don’t believe that they can be successful. Successful athletes,
                 business executives, generals, carpenters, etceteras, on the other hand,
                 have the ability to visualize the outcome of their pursuits. That is, before
                 they begin a project they see, in their mind’s eye, the outcome they want
                 to achieve and have the experience of enjoying the rewards of being
                 successful. Mohammed Ali would visualize actually being the champ
                 and what that would feel like before his fights. That helped him stay
                 motivated, helped him persist when things weren’t going well, and
                 snatch to “victory from the jaws of defeat.” How did he do this? He did
                 it through guided imagery exercises. In fact, all successful people use
                 guided imagery to help them be successful. So, look over your life goals
                 so that you know where you want to be five years from now. You will
                 then have a chance to experience the rewards of being successful.


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                 We start the guided imagery with a relaxation exercise. The goal of the
                 exercise isn’t so much to achieve relaxation but to help the participants
                 shift attention from outside to inside and to remove mental distractions
                 so that they can focus on the task. Please feel free to substitute your own
                 relaxation exercise for the one here. Moreover, feel free to embellish and
                 add to the imagery experience for each of the life goals that are covered.

                 SCRIPT

                 Get as comfortable as you can in the chair. Let’s begin by taking a
                 couple of nice, easy, deep breaths. As you breathe in and out you can
                 become aware of the contact of your body against the chair, the
                 temperature of the room, the sounds outside, and your own breathing.
                 For the next 20 minutes of clock time there is nothing that you need to
                 think about and no concerns that you have to deal with except your
                 future. While your conscious mind may be skeptical about this exercise, the
                 unconscious mind will be able to develop clear images on the inside that will
                 make a difference.

                 Guided imagery is clearer and works best if you let your eyes close and become
                 relaxed. To help you with this I’m going to suggest that you become aware of
                 your left hand, arm, and shoulder, and that you tell that part of you to “let go and
                 relax—calm control, by letting go.”


                 (Pause)

                 Now, if it’s okay with you, you can shift your attention to your right hand, arm,
                 and shoulder and let go there. Remember that letting go is voluntary, under your
                 control, and just by thinking “let go,” your right hand, arm, and shoulder can
                 become relaxed.

                 Now let’s shift attention to the legs. First, the left leg, left shin and calf, left foot,
                 first become aware of those parts and then…. “let go.” (Pause) Now the right
                 foot, right shin and calf, and right upper leg and thigh. “Let go” there. “Calm
                 control by letting go.”

                 Now become aware of your stomach and relax your stomach by letting
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                 go. Enjoy the feelings of calm and relaxation that come with letting go of
                 muscle tension. (Pause) Now do the same with your chest muscles.
                 “Calm control by letting go.” Breathing in relaxation and breathing out tension.




                 (Pause)
                 Now focus your attention on your back muscles, your
                 lower back and upper back, and “let go.” Notice that as you think to
                 yourself, “let go,” your muscles and body become more relaxed and you learn the
                 process of mind-body communication. How the thoughts and images that you
                 have can influence your behavior. You can, by changing your thoughts and mental
                 images, change your behavior, your possibilities and your future.

                 Now for the facial muscles, first become aware of your jaw and neck
                 muscles. Let them relax. “Calm control by letting go.” (Pause) And then the
                 muscles around your nose and eyes, let go there. Letting go further in your
                 forehead and temples. “Calm control by letting go.”


                 Crystal Ball Imagery Exercise

                 Now, I’d like to ask you to imagine in your mind’s eye a “crystal ball.”
                 The crystal ball allows you to see five years into the future. Look into
                 the crystal ball and see yourself. Notice how you look, the changes that
                 have taken place. You’re a little older now, maybe showing some gray
                 hair, you may need glasses, but you’re definitely healthy. Notice where
                 you are living and who is there. You have achieved your relationship
                 and family goals and you can enjoy the feelings of being loved, loving
                 others, feeling safe and supported, supporting and teaching your loved
                 ones, helping them grow and learn. It’s a nice feeling being connected.
                 Close relationships are one of the things that make life worthwhile.

                 You also have the satisfaction of achieving, or being far along in
                 reaching, your school and/or work goals. You know that you can earn a living and
                 support yourself and your loved ones. You also know that you are competent. See
                 that very clearly. There are things that you can do that are as good, if not better,
                 than others can do. Allow yourself to enjoy the feelings of pride that come with
                 being able of doing a job well done. You can hold your head high, notice that,
                 and walk a little taller, maybe a little cocky, but you’ve earned it.

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                 It’s also nice to know that you have the respect of your friends and
                 community for overcoming so many obstacles and being a success. Now
                 you’re looked up to as a leader in your community. Your friends like




                 hanging around you and being in your company and you in their
                 company. You now really belong, and enjoy those feelings of belonging. You
                 really matter and make a difference in the lives of other people.
                 The world would be much poorer without you and is much richer
                 because of you.

                 And you enjoy your free time. You’ve developed new interests. I don’t
                 know if these new interests are in sports, perhaps golf, fishing,
                 basketball, or in music or the arts, or hobbies. Maybe it’s not one thing,
                 but a number of new interests. You maybe so busy that you don’t have
                 time to remember the hard times and the hard time. And, that’s okay.

                 And it’s okay because now you are a lot more relaxed, a lot less angry,
                 and a lot wiser. The more that you’ve learned, the less you know for
                 sure, and that has made you so much more intelligent—about life, about
                 people, about family. There were important things that you wanted to
                 change about yourself, and you have. Everyone tells you that you are
                 different in positive ways, and you are. Enjoy those feelings of being
                 positively different. It’s just not physical or psychological but spiritual
                 as well. You really feel connected to that “higher power.” For everyone,
                 that higher power is different. For some it’s God, for others it’s Allah,
                 for some it’s an inner power, and for others something different. But, it
                 is unmistakable—that spiritual connection. Let yourself enjoy the
                 feelings of peace and calm that come with being right with you and that
                 higher power.

                 And gazing into that crystal ball you can see all of those things and
                 enjoy all of those feelings. You can be with people that you care about
                 and be alone with yourself in ways that five years ago could hardly be
                 imagined. And, it’s time to enjoy the feelings of success that come with a
                 job well done. It took time. It took lots of effort. There were many
                 obstacles to overcome and some setbacks. But, you made it. You really
                 made it. See it, feel it, enjoy it and know that it is in your future. Enjoy.

                 Unfortunately, it’s time to put that crystal ball away and come back to
                 the here and now. When you want to you can get it out again and look it into it

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                 and your future and enjoy the experience. In fact, it may help to
                 do this in the evening before you fall asleep to remind yourself of where you are
                 headed.




                 I’m going to count from 5 to 1. At the count of 5 shake your legs, at 4
                 shake your hands, at 3 open your eyes, at 2 clear your throat and give a good
                 hmmmm, and at the count of 1 get ready to talk about your crystal ball experience.
                 5 (pause), 4 (pause), 3, 2 (pause) and 1.

                        At this point lead a discussion of what the crystal ball experience
                     was like for the participants. Ask them to share what they saw in their
                     crystal balls. Make sure that they cover each of the life goals.
                     Emphasize that in order to make their futures real, they have to be
                     able to see the end of the path and know that reaching their goals will
                     happen.




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                                         Module 50 Main Points



      Having a very strong and complete mental image of your future goals makes it more likely that you
      will achieve them.

      The future can be better than the past. It depends on your future choices.

      Starting and completing this group was a very good choice. Stay on the same path if you want a better
      future.




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                 Appendix A-Table of Contents for Participants’ Handout Packet


             MODULE 1: The Connection Between Substance Use and Mental Health ………….. 3

             MODULE 2: The Complicated Interaction of Two Disorders …………... ……………5

             MODULE 3: The Effect of Two Disorders Interacting …………... ………………….11

             MODULE 4: Using Drugs to Control Psychiatric Symptoms ……………………… 13

             MODULE 5: Antecedents, Behavior and Consequences …………………………… 15

             MODULE 6: Making a Commitment to Change ……………………………………21

             MODULE 7: Barriers to Change …………………………………………………...25

             MODULE 8: Thoughts, Feeling and Behavior……………………………………....29

             MODULE 9: Understanding Thoughts, Feeling and Behavior ………………………31

             MODULE 10: Attitudes and Relapse………………………………………………..39

             MODULE 11: What is Depression? ………………………………………………. .41

             MODULE 12: Depression and Substance Abuse ……………………………………43

             MODULE 13: Fear and Anxiety ……………………………………………………45

             MODULE 14: Understanding Posttraumatic Stress Disorder …………………….....47

             MODULE 15: What is Bipolar Disorder? …………………………………………..49

             MODULE 16: What is Schizophrenia? ……………………………………………..53

             MODULE 17: Distorted Thinking ……………………………………………….....57

             MODULE 18: How to Recognize a Problem ………………………………………..61

             MODULE 19: Stressful Events …………………………………………………….63

             MODULE 20: Analyzing and Responding to Problems……………………………..65

             MODULE 21: Solving Real Life Issues ………………………………………..…...67

             MODULE 22: Craving Drugs ……………………………………………………..71

             MODULE 23: Triggers …………………………………………………..………..73

             MODULE 24: Avoiding Triggers ………………………………………………….77
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             MODULE 25: Control of Cravings and Urges ……………………………………..79

             MODULE 26: Anti-Craving Exercises ……………………………………………..81

             MODULE 27: Managing Thoughts of Your Drug of Choice………………………...83

             MODULE 28: Practicing Self-Talk and Coping Thoughts ………………………….87

             MODULE 29: What is Relapse Prevention?………………………………………...93

             MODULE 30: Lifestyle Balance …………………………………………………...95

             MODULE 31: Coping with Stress …………………………………………………99

             MODULE 32: Meditation ………………………………………………..………..103

             MODULE 33: High-Risk Situations ………………………………………………..107

             MODULE 34: Relapse Set-Ups ……………………………………………………111

             MODULE 35: Self Monitoring for Signs of Relapse: Substance Abuse……………...115

             MODULE 36: Recognizing Early Signs of Relapse …………………………..…….119

             MODULE 37: Self Assessment of Life Goals………………………………………..121

             MODULE 38: Self Monitoring for Signs of Relapse: Mental Illness…………………125

             MODULE 39: Early Warning Signs of Mental Illness Relapse……………………...129

             MODULE 40: Identifying Early Signs of Criminal Behavior Relapse……………….131

             MODULE 41: High-Risk Situations for Criminal Behavior Relapse…………………135

             MODULE 42: Triggers, Cravings, Urges-Revisited…………………………………137

             MODULE 43: Managing Triggers, Cravings, and Urges………………..…………..141

             MODULE 44: Lapse and Relapses …………………………………………………145

             MODULE 45: Recovery Networks …………………………………………………149

             MODULE 46: Relapse Prevention Plan ……………………………………………151

             MODULE 47: Benefits of Leading a Healthy Lifestyle…… ………………………...157

             MODULE 48: Values Clarification………………………………………………....163

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             MODULE 49: Goals for the Next 5 Years …… ………………………..…………...179

             MODULE 50: Envisioning Your Future…………………………………………....183




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                                    Table of Contents for Participants’ Handout Packet



             MODULE 1: The Connection Between Substance Use and Mental Health ………….. 3

             MODULE 2: The Complicated Interaction of Two Disorders …………... ……………5

             MODULE 3: The Effect of Two Disorders Interacting …………... ………………….11

             MODULE 4: Using Drugs to Control Psychiatric Symptoms ……………………… 13

             MODULE 5: Antecedents, Behavior and Consequences …………………………… 15

             MODULE 6: Making a Commitment to Change ……………………………………21

             MODULE 7: Barriers to Change …………………………………………………...25

             MODULE 8: Thoughts, Feeling and Behavior……………………………………....29

             MODULE 9: Understanding Thoughts, Feeling and Behavior ………………………31

             MODULE 10: Attitudes and Relapse………………………………………………..39

             MODULE 11: What is Depression? ………………………………………………. .41

             MODULE 12: Depression and Substance Abuse ……………………………………43

             MODULE 13: Fear and Anxiety ……………………………………………………45

             MODULE 14: Understanding Posttraumatic Stress Disorder …………………….....47

             MODULE 15: What is Bipolar Disorder? …………………………………………..49

             MODULE 16: What is Schizophrenia? ……………………………………………..53

             MODULE 17: Distorted Thinking ……………………………………………….....57

             MODULE 18: How to Recognize a Problem ………………………………………..61

             MODULE 19: Stressful Events …………………………………………………….63

             MODULE 20: Analyzing and Responding to Problems……………………………..65

             MODULE 21: Solving Real Life Issues ………………………………………..…...67

             MODULE 22: Craving Drugs ……………………………………………………..71

             MODULE 23: Triggers …………………………………………………..………..73

             MODULE 24: Avoiding Triggers ………………………………………………….77
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             MODULE 25: Control of Cravings and Urges ……………………………………..79




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             MODULE 26: Anti-Craving Exercises ……………………………………………..81

             MODULE 27: Managing Thoughts of Your Drug of Choice………………………...83

             MODULE 28: Practicing Self-Talk and Coping Thoughts ………………………….87

             MODULE 29: What is Relapse Prevention?………………………………………...93

             MODULE 30: Lifestyle Balance …………………………………………………...95

             MODULE 31: Coping with Stress …………………………………………………99

             MODULE 32: Meditation ………………………………………………..………..103

             MODULE 33: High-Risk Situations ………………………………………………..107

             MODULE 34: Relapse Set-Ups ……………………………………………………111

             MODULE 35: Self Monitoring for Signs of Relapse: Substance Abuse……………...115

             MODULE 36: Recognizing Early Signs of Relapse …………………………..…….119

             MODULE 37: Self Assessment of Life Goals………………………………………..121

             MODULE 38: Self Monitoring for Signs of Relapse: Mental Illness…………………125

             MODULE 39: Early Warning Signs of Mental Illness Relapse……………………...129

             MODULE 40: Identifying Early Signs of Criminal Behavior Relapse……………….131

             MODULE 41: High-Risk Situations for Criminal Behavior Relapse…………………135

             MODULE 42: Triggers, Cravings, Urges-Revisited…………………………………137

             MODULE 43: Managing Triggers, Cravings, and Urges………………..…………..141

             MODULE 44: Lapse and Relapses …………………………………………………145

             MODULE 45: Recovery Networks …………………………………………………149

             MODULE 46: Relapse Prevention Plan ……………………………………………151

             MODULE 47: Benefits of Leading a Healthy Lifestyle…… ………………………...157

             MODULE 48: Values Clarification………………………………………………....163

             MODULE 49: Goals for the Next 5 Years …… ………………………..…………...179

             MODULE 50: Envisioning Your Future…………………………………………....183


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              Module 1 Handout: Relationship


                            Relationship Between Substance Use and Mental Health




                    Biological Factors                     Environmental Factors

                                Risk Factors                           Risk Factors
                      Close biological relative with         Life stressors
                      a disorder                             Relationship issues
                      Personality traits (high risk)         Health & mental health
                      Gender
                      Ethnicity
                                                                   Protective Factors
                            Protective Factors               Coping skills (reduce stress)
                      No family history of substance         Treating substance use & mental
                      use or mental health problems          health problems
                      Adaptive personality traits




                      Substance Use                                  Mental Health




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                                         Module I Main Points


      Biology and environment can and do interact to create both mental health issues and substance abuse
      disorders.

      Risk factors make you more likely to develop a mental health issue or substance abuse disorder.

      Protective factors help prevent the development of mental health issues or substance abuse
      disorders.

      You want to increase your protective factors and decrease your risk factors.




                                                 Module 2
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              Module 2 Handout: Drug Effects



                                     Effects of Different Psychoactive Substances

             Substance Type   Specific Substances     Long Term Effects of Abuse Short Term Effects of
                                                                                   Abuse

             Alcohol          Beer, wine, “hard         *Alcoholism / unmanageable       *Relaxation, sedation
                              liquor” (E.g., vodka,      life                            *Slowed reaction time
                              scotch, whiskey, gin,     *Increased risk of liver         *Impaired judgment
                              rum, tequila)              disease, brain damage, car      *Loss of inhibition
                                                         accidents, other diseases
                                                        *Risk of death from alcohol
                                                        poisoning
                                                        *Decreased sex drive
                                                        *Impotence
                                                        *Depression
                                                        *Sleep problems


             Cannabis         Marijuana, hashish        *Addiction / unmanageable        *Relaxation
                                                         life                            *Mild euphoria
                                                        *Brain damage                    *Altered sensory
                                                        *Decreased motivation             experiences
                                                        *Difficulty concentrating        *Fatigue
                                                        *Mood swings                     *Anxiety
                                                        *Decreased sex drive             *Panic
                                                        *Impotence                       *Increased appetite
                                                        *Interferes with conception of   *Paranoia
                                                         children


             Stimulants       Cocaine                   *Addiction / unmanageable        *Increased alertness
                              Amphetamines (and          life                             and energy
                              related compounds)        *Unmanageable life               *Decreased appetite
                                                        *Brain damage                    *Positive feelings
                                                        *Difficulty concentrating        *Anxiety
                                                        *Mood swings                     *Tension, feeling
                                                        *Increased risk of fatal heart    jittery, heart racing
                                                         attack or stroke                *Paranoia
                                                        *Increased risk of lung
                                                         disease, other diseases




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                                        Effects of Different Psychoactive Substances
             Substance Type      Specific Substances      Long Term Effects of Abuse Short Term Effects of
                                                                                       Abuse

             Sedatives           Anxiolytic (anxiety        *Addiction                      *Sleepiness
                                 lowering)                  *Risk of death from             *Relaxation
                                 medications (e.g.,          overdose                       *Loss of motor
                                 Xanax, Klonopin,           *Depression                      coordination
                                 Ativan, Valium)            *Decreased motivation           *Loss of inhibition
                                 Barbituates                *Increased risk of HIV/AIDS,    *Dulled sensory
                                                             hepatitis, other diseases       experiences
                                                            *Decreased sex drive
                                                            *Impotence


             Inhalants           Glue                       *Addiction / unmanageable       *Altered perceptions
                                 Aerosols                    life                           *Disorientation
                                 Nitrous oxide              *Severe brain damage
                                 (laughing gas)             *Death, liver/ kidney failure
                                 Freon


             Over-the-counter    Antihistamines and         *Addiction                     *Sedation
             medications         related compounds          *Greatly increased risk of
                                 (e.g., benadryl, other      heart disease, lung diseases,
                                 cold tablets)               all types of cancer, other
                                                             diseases.
                                                            *Increased risk of death
                                                            *Decreased immune function
                                                            *Decreased sex drive
                                                            *Impotence


             Tobacco             Cigarettes                                                 *Alertness
                                 Pipe tobacco                                               *Relaxation
                                 Chewing tobacco
                                 Snuff


             Caffeine            Coffee                                                     *Increased alertness
                                 Tea
                                 Chocolate

             Anti-Parkinsonian   Cogentin, Artane,                                          *Confusion
             Agents              Symmetrel                                                  *Mild euphoria




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               Module 2 Handout: Environment versus Biology




                    1. Imagine that risk factors and protective factors for substance use problems are on
                        competing sides of a scale. Create two scales, one or biological factors and one for
                        environmental factors. For each one, make a list of your risk and protective factors.
                        See which side is heavier (i.e., which side has the greatest number of factors). What
                        does this tell you about your level of risk for substance use problems?




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             2. Which is stronger for you right now, risk or protective factors?

             3. What are some things you can do to reduce your risk factors and enhance your
                protective factors?

             4. Do exercises 1-3 for mental health problems.




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                                          Module 2 Main Points

      People’s biology and the environments in which they live and work interact to make them
      more or less likely to develop substance use and mental health issues.
      Biology and environment also affect how severe these issues can become.
      Specific combinations of biology and environment influence how people think, feel, and act and
      are called risk factors or protective factors, depending on whether they increase or decrease
      people’s well-being and functioning.

      Substance use and mental health issues can be the results of other risk factors and can
      themselves be risk factors for each other or other problems.

      Seeking treatment for substance use or mental health problems can reduce
      people’s risk for further problems and would be considered a protective factor.

      Effective treatments for substance use and mental health problems include individual and
      group therapy, support groups, and medication.




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                                                Module 3 Main Points

      Theories regarding interaction of substance abuse and mental health:

      Exacerbate- Street drugs make the mental health problem worse.

      Precipitate- One disorder causes the other to occur.

      Masking- Substance abuse disorder “hides’ mental health disorder.

      Co-Exist- Both occur at same time and interact.

      Exist Independently- Both occur at the same time but do not interact.

      Mimic- Substance abuse creates “temporary” symptoms that look like mental health issues.




   Substance Abuse

                                                    Mental Health




                            Criminal Behavior




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              Module 4 Handout: Why I Used

             Module Handout: Self Medication
             Think about an experience or recent episode when you were using substances that you think
             might have been in an attempt to relieve some painful feelings, or to alter your mood in some
             way. Describe this experience in as much detail as possible.

             I was feeling:




             I took:




             At first, this made me feel:




             After awhile, I felt or experienced:




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                                          Module 4 Main Points



      Self Medicate- This is when a person uses street drugs to treat their mental health issues. Doesn’t work
      very well long term.
         o Often make symptoms worse
         o Wrong type of drug chosen, i.e. marijuana for depression
         o Increased use
         o More problems


      Only you are responsible for the choices you make!




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                  Module 5 Handout: A B C Examples

             1.     BILL FEELS HUNGRY. HE EATS A PIECE OF FRESH-BAKED PIE. HE FEELS
                    MUCH BETTER.


             2.     MR. JONES SEES HIS FRIEND SITTING ON THE PORCH. HE WALKS ACROSS
                    THE STREET, SITS DOWN AND BEGINS TO TALK. IN A FEW MINUTES HE IS
                    LAUGHING.


             3.     A CAT WALKS UP TO FOUR-YEAR-OLD MARK. HE REACHES OUT AND
                    SQUEEZES THE CAT TOO HARD. THE CAT SCRATCHES MARK.


             4.     BOB'S WIFE COMES HOME FROM WORK, WALKS INTO THE KITCHEN AND
                    SAYS "HELLO!" CHEERFULLY. BOB, WHO IS IN A BAD MOOD, SNAPS AT
                    HER. SHE TURNS AROUND AND QUICKLY LEAVES THE ROOM.


             5.     SIX-YEAR-OLD BILLY FEELS LONELY. HE RUNS AROUND THE HOUSE
                    YELLING AND FALLING DOWN. MOM YELLS AT BILLY. THIS HAPPENS
                    SEVERAL TIMES EVERY DAY.




                    Adapted from: West, H., Dupree, L., & Shoenfeld, L. (1988).




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               Module 5 Handout: Vignettes


              (VIGNETTE #1)

             Mr. Smith wakes up on Saturday morning and realizes he has nothing planned to
             do during the day. He feels depressed and lonely. He goes to make a cup of coffee to
             drink while he thinks. When he opens the refrigerator, he sees the beer he
             bought recently for his brother who was visiting. Although he rarely drinks, he gets a
             beer out and opens it. By the time he has finished it, he feels like having another beer.
             By the time he quits, he feels despondent and nauseous.


             (VIGNETTE #2)

             Mr. Smith wakes up on Saturday morning and realizes he has nothing planned to
             do during the day. He feels depressed and lonely. He goes to make a cup of coffee to
             drink while he thinks. When he opens the refrigerator, he sees the beer he
             bought a few months ago for his brother who was visiting. He thinks about
             drinking a beer, but knows it will only result in his feeling worse, so he opens the beers
             and pours them down the sink. Mr. Smith feels stronger and more in control since he
             was able to resist this latest temptation.




             Some material adapted from:
             West, H., Dupree, L., & Schonfeld, L. (1988).




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              Module 5 Handout: Mr. Smith’s Situation




                                                                                NAME   _______________

                                                                                DATE   _______________


                      ABC ASSESSMENT: VIGNETTE #1 (MR. SMITH'S SITUATION)


             1.       WHAT DID MR. SMITH DO? (WHAT IS THE BEHAVIOR WE ARE INTERESTED
                      IN?)




             2.       LIST WHAT PROMPTED MR. SMITH TO DO IT? (LIST ALL ANTECEDENTS)




             3        LIST ALL THE RESULTS (CONSEQUENCES) OF MR. SMITH'S BEHAVIOR.




             4.       INDICATE WHETHER THE CONSEQUENCES ARE POSITIVE (+) OR NEGATIVE
                      (-) OR BOTH (+-) BY PLACING A (+) OR (-) OR (+-) BESIDES EACH
                      CONSEQUENCE LISTED IN NUMBER 3.




             Adapted from: West, H., Dupree, L., & Schonfeld, L. (1988).




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                  Module 5 Handout: Mr. Smith’s Situation



             Mod Handout: Mrs. Smith’s Situation
                                                                 NAME_______________

                                                                 DATE_______________


                     ABC ASSESSMENT: VIGNETTE #2 (MR. SMITH'S SITUATION)


             1.      WHAT DID MR. SMITH DO? (WHAT IS THE BEHAVIOR WE ARE INTERESTED
                     IN?)



             2.      LIST WHAT PROMPTED MR. SMITH TO DO IT? LIST ALL ANTECEDENTS.




             3       LIST ALL THE RESULTS (CONSEQUENCES) OF MR. SMITH'S BEHAVIOR.




             4.      INDICATE WHETHER THE CONSEQUENCES ARE POSITIVE (+) OR NEGATIVE
                     (-) OR BOTH (+-) BY PLACING A (+) OR (-) OR (+-) BESIDES EACH
                     CONSEQUENCE LISTED IN NUMBER 3.




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                                          Module 5 Main Points


      Behavior can be looked at has having three main parts- antecedents, actual behavior and consequences

      An antecedent is what comes before the behavior. It can be said to be the cause of the behavior.

      The behavior is the action and response to the antecedent.

      The consequence is the result. Consequences can be good and bad and sometimes it’s
      difficult to tell which it is.



         ANTECEDENT                BEHAVIOR                CONSEQUENCE




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                Module 6 Handout: Motivation Matrix




             Module 9 Handout: Motivation Matrix
             List your reasons for changing:                                          1 = weak; 5 = strong




             List the reasons why others want you to change:




             Write these in the appropriate box below:

                         WEAKEST MOTIVATOR                          STRONGEST MOTIVATOR

             SOURCE
             Self
                   |______________________|________________________|


             Someone Else
                     |______________________|________________________|

                         1               2                3               4                      5




             Adapted from:
                  Coovert, D.L. (1988). Motivations Worksheet: An interactional model. Unpublished.




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               Module 6 Handout: Commitment


             Module 9 Handout: Commitment
             According to the dictionary to COMMIT is... . "to do, perform or perpetrate, to
             pledge oneself to a position on some issue, to bind or obligate, as by a pledge."

             You cannot change what has already happened to you but you CAN change what
             happens next. Your presence here shows that you've made a COMMITMENT to
             change.

             Abstinence from alcohol and other illicit, non-prescribed drugs and addressing your
             mental health symptoms requires a strong commitment to yourself and the program.
             Agreeing to a lifestyle free from crime also requires a significant
             commitment. We would like you to take a moment to consider the strength of the
             commitment you are making. In the space below consider what is likely to
             strengthen or weaken your commitment to recovery.


             Things that strengthen            Things that weaken
             my commitment                     my commitment

             Example:                          Example:
             My family's support               Thinking about losing friends because I can't party with them


       Things that strengthen my commitment                         Things that weaken my commitment




             Adapted from: Levy, S., (1988).

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               Module 6 Handout: Honesty
             According to the dictionary the word HONEST means "Not lying, cheating,
             stealing or taking unfair advantage; honorable; truthful; trustworthy. Not
             characterized by deception or fraud; genuine."

             Truth is one of the first "casualties" of an addictive lifestyle. Addicts lie to protect
             and hide their addiction - they lie to others by denying or minimizing their drug use
             and the problems it causes - but worse than that they lie to themselves! Addicts
             wage "psychological warfare" against themselves and the people in their lives who
             matter. The first step in any war is to cease hostilities. This is why all treatment
             programs place the value of HONESTY right up front where it belongs.

             As a first step in practicing personal honesty we want you to deal with the
             DENIAL that has surrounded your use of alcohol and other drugs. Denial is a
             word meaning the lies we tell ourselves to keep from having to admit to ourselves
             we have a problem. In your own words, write down below the lies you tell
             yourself in order to keep on using drugs and alcohol, and think about how this is
             related to your mental health symptoms, or involvement in criminal behavior:
             THE LIES I'VE TOLD MYSELF ABOUT MY USE OF ALCOHOL OR DRUGS:




             THE LIES I'VE TOLD OTHER PEOPLE:




             Adapted from: Levy, S., (1988)




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                                            Module 6 Main Points


      Change is hard and difficult to do.

      People often want to change and don’t want to change at the same time.

      It is easier to change if you are doing for yourself (self motivated), as opposed to doing it for
      other people.

      Change requires commitment.

      Change requires honesty.




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             Module 7 Handout: Warning Signs

             0 Handout: elapse Signs
             1.     DENIAL: "I can quit anytime I want to" or "I'll just smoke marijuana but I won't do coke
                    anymore."

             2.     OVERCONFIDENCE: "It's all behind me now...there's no chance I'll ever do that again."

             3.     DEFENSIVENESS: "I don't have a real drinking problem - I just happened to get a few
                    DUI's." This is a lot like denial, but with added rationalizations or excuses.

             4.     COMPULSIVENESS: Overworking and/or compulsive about activities and overextending
                    yourself. This is a form of "hiding out" and avoiding dealing with your thoughts about
                    continued abstinence. Just because you're not working on your problems doesn't mean
                    your problems aren't working on you.

             5.     IMPULSIVENESS: Acting without thinking, in many cases a reaction to stress.
                    Impulsive acts can have far-reaching consequences

             6.     LONELINESS: Isolation, avoiding other people, feeling alone. Solution - socialize, call a
                    friend, go to an AA meeting, visit a relative.

             7.     TUNNEL VISION: Looking at only one area of your life. Could be a good area, creating
                    a false sense of well being and security, or a bad area, emphasizing feelings of being
                    treated unfairly by other people and a victim of bad luck. "Once I get off booze, life will be
                    a breeze."

             8.     LACK OF PLANNING: Wishful thinking instead of realistic planning. Life owes you
                    nothing. If you want to "succeed" in life, be prepared to put forth some effort.

             9.     EXCESSIVE ANGER: Periods of anger, frustration and irritability. Is this an "excuse" to
                    use drugs or drink?

             10. "SELLING" SOBRIETY: Trying to hound everybody else to give up drugs/alcohol is
                  often a sign of your own self-doubts. "Sell" yourself. Let others make their own decisions.

             11. WISHFUL THINKING: Hard work is replaced by fantasy. "If I just had a decent job." or
                 "If I just wasn't so behind on my bills." If you want a decent job, do what you need to do to
                 get one (training, apply for a job, do good at the job you now have to establish a good
                 "track record"). If you don't want to be behind on your bills, do something about it (pay
                 them off - remember, you will probably have more money now that you're not spending a
                 fortune on drugs or alcohol; negotiate lower monthly payments). TAKE POSITIVE
                 ACTION - you live your life by DOING.
             Adapted from: T. Gorski (1988)




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               Module 7 Handout: The Big 3

             Module 10 Handout: The Big Three
             Think about your experience with trying not to drink or use. What has happened before in your
             experience? Fill in two of the three examples below.


             Feeling Down: When was the last time you were angry, frustrated, sad, or bored and you ended up
             having a drink/smoke/snort?




             Fights: When was the last time that you felt very angry or upset while having a fight or
             disagreement with someone and you wound up having a drink/smoke/snort?




             Peer Pressure: When did you have a drink/smoke/snort just because everyone else was or
             because someone offered you something, even though you were trying to abstain?




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                                         Module 7 Main Points


      Change does not happen in a straight line. Sometimes we fall back into old behaviors.

      There are some common signs that our change is growing shaky.

      The 3 biggest signs to watch out for are:
        o Feeling down about life and the changes that we made.
        o Fighting with family, friends, and coworkers.
        o Giving in to peer pressure




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                 Module 8 Handout: F.L.A.S.H. (F L A S H)

             •      If we tune into ourselves, we are usually experiencing either a physical or
                    emotional feeling.

             •      Examples of PHYSICAL feelings are: pain, hunger, hot etc.

             •      Examples of EMOTIONAL feelings are: Fear, Love, Anger, Sad, Happy
                    (FLASH)


             The definition of FEAR = What you feel when you believe you know
             something is going to happen to you (a future expectation /belief) and it is
             not going to be pleasant.

             The definition of LOVE = What you feel when your only want is to give
             (a current giving expectation/belief).

             The definition of ANGER = What you feel when you do not get what you
             want (an unmet expectation/belief} and you still intend to try
             and get it.

             The definition of SAD = What you feel when you do not get what you
             want (an unmet expectation/belief} and you have given up hope of ever
             getting it, even though you still want it.

             The definition of HAPPY = What you feel when you get what you want
             (an expectation/belief met).




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                                         Module 8 Main Points


                   THOUGHTS                  FEELINGS              BEHAVIOR



      Everyone has feelings.

      Our feelings can drive our behavior.

      Feelings are often based on what we expect or believe.

      Fear, Love, Anger, Sadness, and Happiness are basic emotions based on different expectations or
      beliefs about people and situations.




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             Module 9 Handout: Thoughts,Feelings,Behavioro , Feeling and Behavior
             Statements

             Participants’ Version
             1.     Frank was sad about attending group today.

             2.     Janet gave Frank a hug.

             3.     Terry assumed that everyone would like the game.

             4.     Ruby pointed at the television.

             5.     Randy was happy when he earned a weekend pass.

             6.     John needed to visit his brother.

             7.     Jack was happy that his family was coming to visit this weekend.

             8.     Carl whispered to Joyce, “Don’t worry.”

             9.     Lucy realized that she shouldn’t have yelled.

             10.    Rhonda is painting a picture.

             11.    Margaret’s friends consider the movie to be good.

             12.    Joyce was fearful about meeting with the doctor.

             13.    Dorothy was angry when she had not earned an overnight pass.

             14.    The nurse pushed the medication cart towards the doctor’s office.

             15.    Lucy expects to be able to help people.

             16.    Margaret yelled, “It’s medication time.”

             17.    Brian was amazed at how easily he could hit the target.

             18.    Patrick was fearful about his turn to play the game.

             19.    People often laugh at funny jokes.

             20.    Lisa was sad when she had not received a pay raise.




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               Module 9 Handout: Thoughts,Feelings,Behavioro


             21.    Anna wished the dessert would be chocolate cake.

             22.    Harold and Betty believed that they should attend the group together.

             23.    Suzie smiled when told that she had won the prize.

             24.    Mona was fearful when her picture would not look as nice as Marsha’s.

             25.    Marsha was angry when she ate lunch on the unit.

             26.    Walt drew a picture on the board.

             27.    Mona decided that her picture looked as nice as Marsha’s.

             28.    Some people like to run for exercise.

             29.    Bonnie was happy when she got money in the letter from her mom.

             30.    Allison wondered whether she should go to the movie or not.

             31.    Johnny fantasized about flying a plane.

             32.    Karen was sad to say goodbye.

             33.    Marty is writing a thank you note to Connie.

             34.    Gary winked at me.

             35.    Sammy understood the assignment.

             36.    Judy was sad about the situation.

             37.    Arlene is angry about being broke.

             38.    A lot of people run for exercise.

             39.    Susan believed that he team would win first prize.

             40.    Jason is smoking a cigar.

             41.    Mona was happy when she finished her picture.

             42.    Jim wants to win the game.



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               Module 9 Handout: Thoughts,Feelings,Behavioro


             43.    Mike expected to be in the Intermediate group.

             44.    William is sad that he is staying on the unit.

             45.    Ellen is sitting on the floor.

             46.    Tina’s friends are happy that she can come home.

             47.    Carl and Tim are eating breakfast.

             48.    Burt considered himself a good team player.

             49.    Sally wants to be alone.

             50.    Martha grabbed the beanbag from Scott.

             51.    Sue was sad to have lost the game.

             52.    Sam was happy he won the game.

             53.    Larry is reading a sports magazine.

             54.    Allen hoped he could be the team captain.

             55.    Phyllis wants to have one more turn at the game.

             56.    Ron didn’t get the prize and was angry.

             57.    Agnes is sleeping in the chair.

             58.    Bernie was fearful to ask for a cigarette.

             59.    Wendy was surprised when the fire alarm sounded.

             60.    Mark tossed the beanbag.

             61.    Ed decided that Martha was uncooperative.

             62.    Susan was happy she won the game.

             63.    Burt talked to Ed about the game.

             64.    Abe was sad Mark missed the target.

             65.    Abe thought Mark would hit the target.

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               Module 9 Handout: Thoughts,Feelings,Behavioro


             66.    Sally whispered, “I can’t play this game.”

             67.    Sally wanted to continue the game.

             68.    Sally pitched a beanbag and hit the target.

             69.    Charlie was sad when Sally won the game.

             70.    Mark was angry when he didn’t get another turn.

             71.    Burt considered himself a good player.

             72.    Sally is smiling at Mark.

             73.    Mark kicked the beanbag across the floor.

             74.    Judy guessed that she would lose the game.

             75.    Judy is happy when she was able to play with the others.

             76.    Sally and Charlie were angry when they were told not to play the game.

             77.    Charlie believed that he and Sally should be able to play the game.

             78.    Tom laughed with Charlie.

             79.    Tony yelled at Wanda for missing the target.

             80.    Patrick wished he could go to the mall.

             81.    Martha loves to play cards.

             82.    Roxanne clapped her hands as the movie ended.

             83.    Arlene desires a new dress.

             84.    Mike was fearful about seeing the doctor.

             85.    Greg is sitting in the chair.

             86.    Ben imagined that Kevin would not go to lunch today.

             87.    Ben was angry when Kevin didn’t show up for lunch.



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               Module 9 Handout: Thoughts,Feelings,Behavioro


             88.    Hilary is juggling tennis balls.

             89.    Peggy decided to go on the picnic.

             90.    Vince was happy Peggy was at the picnic.

             91.    Connie was sad she didn’t pass the test.

             92.    Connie cried after the group.

             93.    Connie believed she would pass the worksheet.

             94.    Stephanie considered the group difficult.

             95.    Margaret is waving good-bye.

             96.    Margaret is sad to be leaving her friends.

             97.    Becky is cooking hamburgers for lunch.

             98.    Jim expects Becky to have lunch with him today.

             99.    Jim is happy about Becky having lunch with him.

             100.   Harold is swimming in the pool.

             101.   John is sad he is sick.

             102.   Harold wanted John to feel better.

             103.   Diane is happy about Fran passing the test.

             104.   Jackie wished she would be able to go home this weekend.

             105.   Tom is walking to the store.

             106.   Jane guessed at the answer to the question.

             107.   Molly laughed at the cartoon.

             108.   Greg was angry when the party was over.

             109.   Larry tripped over the rug.

             110.   Lydia hoped to be elected president.

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               Module 9 Handout: Thoughts,Feelings,Behavioro


             111.   Lydia was happy to be elected secretary.

             112.   Alex is angry about not getting a raise in salary.

             113.   Alex expected a raise in his paycheck.

             114.   Alex ripped up the letter stating he didn’t get a raise.

             115.   Paula has an idea about how to make money for the party.

             116.   Paula is washing cars to make money for the party.

             117.   Tom is happy since Paula is helping to earn money for the party.

             118.   Kelly is writing a poem, on a piece of paper.

             119.   Kelly is fearful that others won’t like her poem.

             120.   Elaine thinks Kelly’s poem is beautiful.

             121.   Sandy grabbed the last balloon.

             122.   Kim is angry she didn’t get a card from her mother.

             123.   Kim expected a card from her mother.

             124.   Frank was sad he missed the concert.

             125.   Marsha is moving the T.V.

             126.   Frank believed he would go to the concert.

             127.   Jack is typing a letter.

             128.   Dick wants to be first in line.

             129.   Dick got angry when he wasn’t first in line.

             130.   Eileen guessed the answer to the question.

             131.   Joe was crying about being late to group.

             132.   Diane was sad when she missed the bus.




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               Module 9 Handout: Thoughts,Feelings,Behavioro

             133.   Peter is painting a picture of a dog.

             134.   Alex is fearful of large dogs.

             135.   Lorie wished she was as good of an artist as Peter.




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                                          Module 9 Main Points


      Thoughts, feelings and behaviors are inert-related.

      It is important to know the difference between a thought, a feeling and a behavior.




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                                         Module 10 Main Points


      There are warning signs and cues that a relapse into drug use or criminal behavior is becoming more
      likely.

      Signs can be negative feelings, bad attitude, risky behaviors and negative thoughts.

      You should have thought of a plan of action before you encounter one of these four factors. That way,
      you will have a solution and support ready to go as soon as needed.

      A few possible coping strategies:
         o Keep repeating to yourself why you need to maintain a total abstinence.
         o Ask treatment personnel to give you feedback when they hear you expressing negative attitudes.
         o Try to arrange "safe situations" for yourself, (situations in which using would be impossible):
            shopping, church, visiting non-using friends.




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                 Module 11 Handout: Symptoms of Sadness and Depression


             and My Diary / “Thinking or Feeling Report”
             SADNESS = What you feel when you do not get what you want (an unmet
             expectation/belief) and you have given up hope of ever getting it, even though

             you still want it.

                                              VERSUS

             Symptoms of: DEPRESSION =

             • Not being able to feel pleasure or enjoy things you used to enjoy

             • Feeling down most days

             • Not having energy to do work/fun things

             • Feelings of worthlessness, hopelessness, helplessness or excessive guilt nearly every day

             •   Diminished ability to think or concentrate or indecisiveness nearly every day recurrent
                 thoughts of death/suicidal ideation.)

             • Lasts for at least two weeks


                                    My Diary / “Thinking or Feeling Report”
             Date and Time                           Symptoms I felt




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                                         Module 11 Main Points


      Sadness and Depression are two very different things.

      Sadness is a natural and time limited reaction to an unmet need or wish.

      Depression is longer term and has a variety of symptoms. It can be caused by a variety and combination
      of factors: current situation, genetics and environmental learning.


   Sadness- short term, cause and effect can be traced

   Depression- long term (2+ weeks), cause and effect can be from several sources and a combination of
   sources




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                                          Module 12 Main Points


      Sometimes people will use street drugs to try to “treat” their Depression. There are several problems
      with this plan:
         o Only a short term fix
         o Can make the Depression even worse.
         o Can “hide” other symptoms and problems.
         o It’s illegal and results in jail and prison.
         o Need more and more to get the same results (tolerance).



      Sometimes people will convince themselves that it is okay to use other street drugs (as long as it is not
      their original drug of choice) to deal with their depression. Again, there are problems with this plan:
         o All the problems listed above.
         o Often the “substitute” drug just makes the user crave their drug of choice all the more.

      Psychotherapy is also an effective treatment, especially when in combination with medication.




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                                           Module 13 Main Points


      Fear and Anxiety are two very different things.

      Fear is a natural and time limited reaction to an event.

   Event                Fear

      Anxiety problems generally are caused by a combination of biological and
      environmental risk factors.

      In many cases, there is no real concrete reason for the anxiety.

   Event/Biology/?               Anxiety

      Limited anxiety can be motivating- You are anxious about how you will do on a test, so you put in a
      few extra hours of studying.

      Unlimited anxiety can interfere with daily life- You are so anxious about how you will do on a test that
      you don’t eat, sleep or go to work for three days and instead spend every moment studying.

      Two common types of Anxiety Disorders
        o Social Anxiety
        o Panic Attacks


       There are legal drugs that can be prescribed for these disorders and they are more effective and
       predictable than street drugs.




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                                         Module 14 Main Points


      Another common Anxiety Disorder is Posttraumatic Stress Disorder (PTSD).
      Memories of a past traumatic event cause severe stress and inability to function.
      Sometimes people will use street drugs to try to “treat” their Anxiety. There are several problems with
      this plan:
          o Only a short term fix
          o Can make the Anxiety even worse.
          o Can “hide” other symptoms and problems.
          o It’s illegal and results in jail and prison.
          o Need more and more to get the same results (tolerance).

      Psychotherapy is also an effective treatment, especially when in combination with medication.




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             Module 15 Handout: Case Studies
             Read the following:
             Case Story 2
             Leo was a young man full of life and potential, but he could never seem to get over that
             final hurdle in life that would, in his words, “make me a success.” Though he was
             married with two kids and appeared to be happy in his middle-class suburban
             neighborhood, Leo could never maintain a steady work history. Luckily he had
             inherited some money and his home from a deceased relative, and his wife worked for a
             medical clinic. If the family had depended solely on Leo providing for them, they
             would have been in trouble.

             One day while meeting his wife at the clinic for lunch, Leo struck up a
             conversation with a psychiatrist who worked at the clinic. As usual, Leo was
             between jobs and began discussing with the psychiatrist how much he hated his
             previous employer and that in all his years he had yet to find a job that made him
             happy. He also discussed his history of mood swings that left him depressed and
             withdrawn from his family and work. During these periods, his alcohol
             consumption would increase drastically, and his experimentation with
             hallucinogens got worse, putting a strain on his marriage and usually resulting in
             another job change. Leo had “tried” over the years to get a grip on his mood
             swings. Every time he assumed he had things under control, his mood swings
             would flare up again, his use of alcohol and hallucinogens would increase, and he
             would change jobs again.

             The psychiatrist asked Leo to make an appointment and suggested he bring his
             wife. At the first appointment, the psychiatrist suggested that Leo try some mental
             and relaxation exercises. Leo was later diagnosed with bipolar disorder and given
             medication.

             Two years later, Leo’s mood swings have subsided, and he no longer uses alcohol and
             hallucinogens. He started his own business, which is thriving, and his life is finally
             looking like he had envisioned when he graduated college.


                Question 5: Why do you think Leo began using alcohol and drugs?




                Question 6: What effect did these substances likely have on Leo’s mood swings?

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                Module 15 Handout: Case Studies
               Read the following:
              Case Story 3
              Lisa had a wonderful life. She had so much going for her. She had three great
              children and was married to a special man. There was so much to do and so much to
              live for - and so little time! One day after watching a television show about
              architects Lisa decided she had found her calling. She would be a cashier by day and an
              architect by night. She began to create designs of houses and office
              buildings, often working late into the night. That was no problem, however,
              because she was so excited about her new calling that she often found she couldn’t sleep
              until quite late anyway.

              Lisa had so many good ideas for building designs that she found it hard to finish
              one design before moving on to the next idea. One evening, while working on a
              new design, Lisa came to the realization that she could also decorate the insides of the
              buildings as well as design the outsides. She should become an architect and
              interior decorator!

              Soon, Lisa’s husband began to turn into a real pessimist, saying things like she
              couldn’t be an architect without being trained or at the very least finishing her high
              school degree. That didn’t stop Lisa; she knew that she had natural ability and that was
              all she needed.
              After a couple more weeks, Lisa found that she could no longer keep up with the
              hectic pace she had set for herself. In fact, she began sleeping more and more,
              sometimes as much as half the day. She also began to feel down on herself,
              thinking that her husband was right - she couldn’t be an architect. What a stupid
              idea. She began to feel guilty for wasting her time and for neglecting her family.
              She began to feel that she was a horrible mother and person and didn’t deserve
              such a wonderful family. Maybe she should just put an end to all the foolishness
              once and for all.
                    Question 7: Identify Lisa’s symptoms of bipolar disorder.



                    Question 8: What drugs might she turn to in order to combat her depressive
                    symptoms?


                     Question 9: What would be the likely result of using these drugs in the short
                     term?
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                   Question 10: What would be the likely result of using these drugs in the long
                   term?




                                           Module 15 Main Points


      Bipolar Disorder is a disorder that consists of very high highs(mania) and very low lows (depression).

      These mood swings affect thoughts, feelings, physical health, behavior, and functioning.

       It is a lifelong disorder, but in between mood episodes, many people can function normally.

      Sometimes people will use street drugs to try to “treat” their Anxiety. There are several problems with
      this plan:
          o Only a short term fix
          o Can make the Bipolar Disorder even worse.
          o Can “hide” other symptoms and problems.
          o Can aggravate the mood swings and make it more difficult to treat.
          o It’s illegal and results in jail and prison.
          o Need more and more to get the same results (tolerance).

      Psychotherapy is also an effective treatment, especially when in combination with medication.

      Support groups exist and can be very helpful.




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             Module 16 Handout: Case Studies
             Read the following:

             Case Story 1
             Barbara had always seemed a bit “odd in her thinking” to many of her friends and
             family. Her mother had once commented that Barbara reminder her of Barbara’s
             father in that respect. He had been diagnosed with schizophrenia shortly after
             Barbara was born. Barbara liked being different, though, so she didn’t mind being
             thought of as “out there”.

             Barbara’s mother died of a drug overdose when Barbara was 17, leaving her alone.
             It was hard trying to support herself because Barbara had trouble keeping a steady
             job. After a while the bills started to pile up. The stress was too much for her.

             Barbara started hearing voices telling her that things were hopeless and that she was a
             bad person. She was also beginning to suspect that she was under
             surveillance by the FBI because they had gotten a tip that she was keeping a cat in her
             apartment without telling her landlord. At any rate, she was certain they were behind
             her getting fired from her last two jobs.

             She was chronically on edge and felt wired all the time. The voices in her head
             were telling her that Barbara should do awful things to her former boss and then
             kill herself. She knew she didn’t want to do that, but the voices were so loud and
             constantly there. It was impossible to ignore them. Barbara started taking
             barbiturates to soothe herself. At least when she slept she couldn’t hear the voices.

               Question 4: What symptoms of schizophrenia can you identify from the story?




               Question 5: Can you identify any risk factors for schizophrenia from the story?




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               Module 16 Handout: Case Studies


             Read the following:

             Case Story 2
             Marcus had a miserable life. His father was killed several years ago in a drive-by
             shooting when Marcus was fifteen. Since then, his mother had brought a string of
             boyfriends home over the years, insisting that he call them “Dad”. The latest one
             had been a real piece of work. He would come home drunk and beat Marcus’
             mother. If he finished with her before passing out, he’d start on Marcus next. A
             year ago, he’d broken Marcus’ jaw with a baseball bat and put Marcus’ mother in
             the hospital.

             Not surprisingly Marcus looked for any way to escape that he could. Some kids in the
             neighborhood had introduced him to a number of different drugs, and he tried them all.
             His favorite was LSD. He liked watching weird things happen right
             before his eyes and often thought that he had the power to control what
             hallucinations he saw. He knew that if he concentrated hard enough he could make them
             actually happen to his “dad”.
             During a particularly rough period at home, Marcus stayed on LSD pretty much all day,
             every day. He started mixing the LSD with other drugs too. One night his “dad” caught
             Marcus stealing money out of his wallet and threw him down the stairs headfirst. When
             Marcus woke up he was in a hospital under restraint. The nurse told him that he’d been
             babbling for several days about melting walls and scooping out his “dad’s” brains and
             feeding them to a dog.

                 Question 7: What symptoms of schizophrenia can you identify from the story?



                 Question 8: Can you identify any risk factors for schizophrenia from the story?




                 Question 9: Why is it hard to determine exactly what is going on in Marcus’ case?



                 Question 10: How might someone go about figuring out what is going on with him?
                        .


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               Module 16 Handout: Case Studies

                 Question 7: What symptoms of schizophrenia can you identify from the story?


                 Question 8: Can you identify any risk factors for schizophrenia from the story?



                 Question 9: Why is it hard to determine exactly what is going on in Marcus’ case?


                 Question 10: How might someone go about figuring out what is going on with him?




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                                          Module 16 Main Points


      Schizophrenia is a major psychiatric disorder.
      Schizophrenia has both positive and negative symptoms.
       Positive Symptoms refer to things that are present in people with schizophrenia but ordinarily absent in
      other people.
      Negative Symptoms refers to- absence of thoughts, perceptions, or behaviors that are present in other
      people.
      Schizoaffective disorder is similar to schizophrenia but involves an additional mood component. The
      symptoms of schizoaffective disorder can be divided into four broad categories:
         o Present symptoms
         o Absent symptoms
         o Mania
         o Depression

      Sometimes people will use street drugs to try to “treat” their Anxiety. There are several problems with
      this plan:
          o Only a short term fix
          o Can make the Bipolar Disorder even worse.
          o Can “hide” other symptoms and problems.
          o Can aggravate the mood swings and make it more difficult to treat.
          o It’s illegal and results in jail and prison.
          o Need more and more to get the same results (tolerance).




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               Module 17 Handout /Homework: Cognitive Distortions
               COGNITIVE DISTORTIONS

             1.    All-or-Nothing Thinking: This happens when you see things as either ‘all one
                   way or all the opposite way’.          When thinking this way there is no middle
                   ground—no compromise. If your performance falls short of perfect, you see
                   yourself as a failure. "I'm a total failure because I didn't finish high school".

             2.    Overgeneralization: This occurs when you see a single negative event as a
                   never-ending pattern of defeat. "I broke up with my girlfriend; I'll never have
                   another relationship".

             3.    Mental Filter: You pick out a negative detail and dwell on it completely.
                   Your ‘reality’ becomes darkened (like the drop of ink that discolors the entire glass
                   of water). "The car wouldn't start, my whole day is ruined".

             4.    Discounting the Positive: You reject positive experiences by insisting they
                   "don't count". In this way you work to maintain a negative belief that is
                   contradicted by your everyday experience. "I may have gotten a good job last year,
                   but I was just lucky".

             5.    Jumping to Conclusions: You make a negative interpretation even though
                   there are no definite facts that convincingly support your conclusion.  “My
                   boss has on a suit today. That means something bad is going to happen.”

             6.    Mind Reading: You arbitrarily conclude that someone is reacting negatively
                   to you, and you don't bother to check this out. "My boss didn't say hi to me this
                   morning, I know she's mad at me".



             7.    Fortune Telling: You anticipate that things will turn out badly, and you feel
                   convinced that your prediction is an already established fact. (“I know that I
                   will fail the GED math section. I’m not taking the test.”

             8.    Magnification (Catastrophizing) or Minimization: You exaggerate the
                   importance         of things (such as goof-up on your part ; another person’s
                   achievement) , or you           inappropriately shrink things until they appear
                   tiny (your own desirable qualities;         another person's imperfections).

                   Magnification: "I can’t type, I'm a failure."

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                   Minimization: "I may have a H.S. degree, but it's not worth much these days".



               Module 17 Handout /Homework: Cognitive Distortions



             9.    Emotional Reasoning: You assume that your feelings reflect the way things
                   are. "I know that everyone feels the same way that I do about taxes."

             10. “Should" Statements: You try to motivate yourself with ‘shoulds’ and
                 ‘should-nots’. You also expect other people to ‘should’ or ‘should-not’ behave in
                 certain ways!. Some results of these demands are guilt, shame, resentment,
                 rebelliousness, anger, disappointment, depression etc. “I should organize a
                 party because no one else will.”

             11. Labeling or Name-Calling: Instead of saying, "I made a mistake", you say
                 "I'm a fool". When applied to other people, whose behavior irritates you, you say,
                 "He's a jerk".

             12. Personalization: You see yourself as the cause of some event over which you
                 were not responsible or had no control. "If I had paid more attention to my
                 brother, he wouldn't have started using crack."




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              Module 17 Handout: Cognitive Distortions Related to Recovery

             1.      My symptoms (sadness/depression, fear/anxiety, anger etc.) are too uncomfortable and
                     they shouldn't be this uncomfortable! I shouldn’t have to deal with them.

             2.      There should be an EASY, MAGICAL WAY to change!

             3.      If I understand how I got this way, I'll easily and magically change, with no effort
                     on my part.

             4.      My therapist should change me!

             5.      I've been this way TOO LONG to change!

             6.      I can only change by venting my feelings (screaming, yelling, blaming others/moaning
                     and whining), and this will magically change things.

             7.      Therapy is too boring. It should be more interesting.

             8.      Therapy is too rigorous if it requires me to DO SOMETHING.

             9.       I'll only change if my therapist and the rest of the world loves me, otherwise,
                      it's TOO HARD.


             CHALLENGE THESE IRRATIONAL BELIEFS

                  1. Ask yourself, "WHY is it TOO HARD?" (Answer: It never is, it can be very
                     hard, but never too hard.)

                  2. Prove that you CAN'T STAND being feeling how you feel. (You're standing it now,
                     so that proves you CAN stand it.)

                  3. Where is the evidence that you should only get just so much frustration and no more?
                     (Answer: There is no evidence. No cutting-off point for frustration. Whatever frustration
                     you have, that's what exists.)    -

                  4. No one else can change you or magically make things easy for you.




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                                          Module 17 Main Points


      There are some ways of thinking that can increase your likelihood to commit another crime or relapse.

      Some ways of thinking can make depression symptoms worse:


                       All-or-Nothing Thinking
                       Over-generalization
                        Mental Filter
                        Discounting or Disqualifying the positive
                        Jumping to conclusions
                       Catastrophizing or minimization
                       “Should” statements
                       Labeling or name calling
                        Personalization




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                                         Module 18 Main Points


      To solve a problem, you must first recognize/ understand that there IS a problem.

      A problem exists when a need, expectation or belief is not being met.

      If the problem is not obvious, you sometimes have to look to find it. Things that might indicate a
      problem:

          o Your own behavior- Has it changed? If so, why? What is driving the change?

          o Input from other people- Are other people telling you that there is an issue? Sometimes others can
             see what we don’t want to look at.




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             Module 19 Handout: Breaking Down the Problem

             Problem- “I need to clean the kitchen and it is a complete mess. It is so dirty that it seems
             overwhelming.”
             1. Gather all of the dirty dishes and place them in sink with soap and water.
             2. Wash the dishes, dry them and put them away.
             3. Soak the pans.
             4. Wipe down the tables, countertops and stovetops.
             5. Sweep and mop the floor
             6. Take out the garbage.
             7. Scrub the dirty pans, dry them and put them away.
             8. Give one final wipe down to counter.


             What first seemed like an impossible task was really only a series of smaller and doable
            steps.
             Remember, the old joke-
             How do you eat an elephant?
             One bite at a time.




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                                          Module 19 Main Points


      Stress often happens because how we are looking at a problem/ situation.

      Many times something will seem “too big” for us to handle.


       The best way to deal with it is to break it down into small bits that you can handle.

      One Day at a Time—One Piece of the Problem at a Time




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                                          Module 20 Main Points


      To decide is something is a problem first ask- Who? When? Where?

      Then ask- What?

      When asking “What?” try to be unbiased. Maybe ask someone else to help you look at situation.

      We can sometimes affect the outcome of a situation by the way that we view and approach it.

       A self-fulfilling prophecy is when our view causes an outcome to occur. For example, I convince
      myself that I am not going to get the job before I even go to the interview because no one will give a
      felon a chance. So, I end up going into the interview with an angry/hostile attitude. I don’t get the job. I
      don’t get the job because of my attitude not because of any bias on the interviewer’s part.




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             Module 21 Handout: Healthy Decisions
             The problem is:




             Brainstorming of possible solutions:




             Top 3 solutions:
             1.
             2.
             3.




                            Solution #1
          + of solution            - of solution




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              Module 21 Handout: Healthy Decisions




                            Solution #2
         + of solution             - of solution




                            Solution #3
         + of solution             - of solution




               Of the 3 solutions, which is your best option?


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                                          Module 21 Main Points


      Identifying that you have a problem and thinking of solutions is a good start but it is not enough.

      Solutions need to be realistically evaluated. What is good about the solution? What is bad about the
      solution?

      After you decide on and begin to use a solution, you must sometimes go back and re-evaluate the
      solution.

          o Is it working the way that you expected?

          o Did it work at first but now longer works?

          o Has a new and better solution become available?




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             Module 22 Handout: Selective Memories



             Situation: You are thinking about getting a dog from the shelter. You think
             about the dog that you had a few years ago.

             You remember:
                    How he was such a nice dog.
                    How he used to greet you when you came home.
                    The fun you had playing with him at the park.
                    How he used to curl up at he end of your bed and keep your feet warm.

             You fail to remember:
                    How he chewed up your expensive work boots.
                    How you had to take him out for a walk- even when you were sick or tired
                    and did not feel like doing so.
                    How expensive it was to feed him and take him to the vet.
              In other words, you use selective memory and only remember the good things about
              owning dog. If you make a decision based only on the good factors, why wouldn’t you get
              another one? This is not a healthy or safe way to make decisions.

              Let’s apply this to your drug use. If you only think about the high and the fun, then what
              reason to do you have to not use. It is vital that you also remember the not so good things
              about substance use.

              For me the not good things about using drugs are:
              1.

              2.

              3.

              4.

              5.



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                                          Module 22 Main Points


      Sometimes our minds play a trick on us and only remember the good or bad about a situation.

      When you only remember the good things about using illegal drugs, you are engaging in “euphoric
      recall.”

      Euphoric recall is dangerous because if there were only good things bout using drugs, then the only
      logical choice would be to use drugs.

      Sometimes we use the “mind trick” to convince ourselves that what we really want to do is in fact the
      best solution. This can be a big factor in our decision to “self medicate”.

          o I want to keep drinking. I only look at the fact that when I drink and am drunk, I feel happy and
             forget my problems. I fail to think about the hangovers, the DUI charges, the family fights, etc.

          o When offered a legal prescription to treat my depression. I only remember the bad things about
             medication. I only remember that it made me gain weight or that it made me have hard time
             falling asleep. I fail to think about the fact that it allowed me to function every day, complete
             parole and stay out of prison.




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             Module 23 Handout: Triggers

             Things that have in the past or may in the future trigger my drug use:

             Sights (ex. seeing someone shoot up)-
             1.
             2.
             3.
             4.
             5.

             Sounds (ex. certain music that I used to listen to while getting high)-
             1.
             2.
             3.
             4.
             5.

             Smells (ex. smell of burning rubber)-
             1.
             2.
             3.
             4.
             5.
             Touch (ex. the feel of sex because I always got high before having sex )-
             1.
             2.
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             3.

             Module 23 Handout: Triggers


             4.
             5.

             Taste (ex. the taste of Taco Bell because I always went there when I was high)-
             1.
             2.
             3.
             4.
             5.

             Feelings (ex. bored because I use when I am bored)-
             1.
             2.
             3.
             4.
             5.

             Thoughts (ex. “staying clean is too hard”)-
             1.
             2.
             3.
             4.
             5.
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             Module 23 Homework Handout: Self Monitoring Record

      Trigger                Thoughts/               Behavior              + Consequences         - Consequences
                             Feelings

      What caused my urge?   What was I thinking &   What did I do then?   What positive things   What negative things
                             feeling?                                      happened?              happened?




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                                            Module 23 Main Points


      It is important to remember that cravings and urges are time limited!

      Whenever possible, it is best to avoid things that trigger your cravings and urges.

      Triggers can affect any of your senses: touch, taste, smell, hearing and sight.

      Common triggers include:

          o    Exposure to alcohol or drugs themselves.

          o    Seeing other people using.

          o    Contact with people, places, times of day, and situations commonly associated with using
              (parties, bars, friends, weekends, before dinner, etc.).

          o Particular types of emotions such as frustration, fatigue, feeling stressed out. Even positive
            emotions such as elation and feelings of accomplishment can be triggers.

          o    Interpersonal stress




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             Module 24 Handout: ACE

             There are 3 main ways to handle triggers:
             A- Avoid them to begin with. This is often the simplest and safest solution.
             C- Cope with being triggered. This can be difficult to do but it is not impossible. We will
             discuss this ore in our next session.
             E- Escape from what is triggering you. This is a good option when a trigger catches you by
             surprise and there is a safe/ easy way to leave the situation.




             Fill in the table below with some common personal triggers that you have.

                 Trigger                  Ways to Avoid            Way to Escape




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                                          Module 24 Main Points


      You can Avoid triggers, Cope with being triggered or Escape from triggers- ACE

      Avoiding triggers should usually be your first option because it is often the easiest and most solid way to
      not be triggered.

      In order to avoid triggers, you must first identify what triggers you.




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                                          Module 25 Main Points


      Cravings are time limited.

      When you can’t avoid or escape a trigger, you have to cope.

      Some good ways to cope include:

          o Distraction: Reading, a hobby, and exercising are good examples of distracting activities. Once
             your mind becomes occupied with something else, you’ll find that the urges will go away.

          o Talk it through: Another way of coping is talking the craving through with someone else.
             Talking about craving and urges can pinpoint the source of the craving. Talking about craving
             also often discharges and relieves the feelings associated with craving.

          o Urge surfing: Many people try to cope with their urges by gritting their teeth and toughening it
             out. But, some urges to certain triggers are hard to ignore. When this happens, you can stay with
             the urge until it passes. This is called urge surfing.

          o Challenge and change your thoughts: When experiencing craving, many people have a
             tendency to only remember the positive effects and to forget the negative effects of using
             drugs or alcohol. It is important when experiencing urges to remind yourself of the benefits
             of not using and the negative consequences of using.

          o Self-Talk Coping Skills: You can use an urge as a signal to give yourself a “pep talk,”
             reminding yourself that you can cope, that you have a plan to deal with these feelings, and that
             you have many personal and social resources that you can use at this time.




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             Module 26 Handout: Urge Surfing Techniques


                 1. Take an inventory of how you experience the craving. You focus your
                 attention on your body and notice where you experience craving. For
                 example, Let me see…My craving is in my mouth and nose and in my
                 stomach.




                 2. Focus on one area where you experience the urge. Notice the exact
                 sensations in that area. Is it hot or cold, tingly or numb, tense or relaxed?
                 How big of an area is involved. Notice the sensations and describe them to
                 yourself? Am I experiencing the smell and taste or feeling of alcohol or
                 drugs?




                 3. Like standing behind a waterfall, just observing the water as it falls
                 down, observe your bodily sensations and your thoughts as they come forth.
                 Don’t criticize them, fight with them, judge them, or anything else. Just observe.
                 Notice how the craving comes and goes. Many people notice that after a few
                 minutes of observing the craving has vanished or that they
                 experience the craving in a new way.




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                                         Module 26 Main Points



      Cravings are time limited.

      Urge surfing can be a good way to cope when you are experiencing an urge.

      Urge surfing is a non- judgmental “going with” the urge rather than fighting it. This is not the same as
      giving into the urge!




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             Module 27 Handout: Dangerous Thought Patterns


                 Nostalgia: There will be times when you remember the good old days as if
                 using were a long lost friend or where using only had positive consequences.

                Testing Control: Alcoholics in particular have the tendency to become
                overconfident about their control over alcohol. They bet that they can have a
                couple of drinks without harmful consequence. They reason that they can easily
                stop again tomorrow.

                Escape: Individuals want to avoid the discomfort associated with
                unpleasant situations, conflicts, and memories. They just want to get away
                from it all. It is not a high that is sought but rather numbness from the
                problems and an inner sense of peace.

                 Relaxation: Thoughts of wanting to unwind are normal. Doing a relaxing
                 activity takes time and effort. The temptation for immediate relief through
                 the use of substances can be strong.

                 Socialization: Many individuals are shy and uncomfortable in social situations, and
                  may “feel” the need for social lubrication in order to feel more at ease and to deal with their
                 inhibitions.

                  Improved Self-Image: Those people with low self esteem feel unhappy with themselves when
                 they are feeling inferior to others, when they believe that they are lacking in certain qualities,
                 when they feel unattractive and deficient and they begin to think about substances as a way to
                 achieve relief.

                 Romance: When people are bored with their lives, they yearn for excitement and
                 romance. They often associate the use of substances to these feelings and begin thinking about
                 using.

                  To Hell With It: Some individuals get to a point in which they lose all incentive
                 to pursue worthwhile goals. Their thoughts express disillusionment; nothing really
                 matters. There is no reason to try. This attitude makes one very vulnerable to a relapse.

                  Crisis: During stress or a crisis, the person thinks that they need to use substances in
                  order to cope. They believe that they just need to use until they get through the crisis and then
                 they’ll stop again.


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             Module 27 Handout: Dangerous Thought Patterns



                 The last time that you relapsed which of these thought patterns did you have?




                 Did you “play the movie thought to the end”? That is, did you look past the instant
                 relief to the consequences that would follow later on?




                 What self-talk can you use to challenge these thoughts?




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                                         Module 27 Main Points


      There are some ways of thinking that greatly increase the chance of relapse.

      It is important that you recognize and challenge these thought patterns when they occur.

      When you are thinking about using, play the movie all the way through to the end. Don’t stop at the
      “good part” when you’re high. Keep on going all the way through to the end that you have already
      experienced at least one. Play it all the way through until you are once again sitting in a cell and
      wearing orange.




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             Module 28 Handout: Coping With Urges-Self Statements



                 Preparing for the Exposure

                 What is going to happen when I... ..?

                 Self-talk strategies (Script #1):

                       1)        This is going to tempt me, but I know how to deal with it.

                       2)        Remember to list all of my coping tactics.

                       3)        The urges will come but I’ll be okay, I know how to cope.

                       4)        Relax-take a deep breath.

                       5)        Easy does it. Remember to keep my sense of humor.


                 Coping When Cravings Start to Build


                 Self-talk strategies (Script #2):

                 1)    It’s time to relax and slow down.

                 2)    My craving is a signal of what I need to do. Breathe...

                 3)    If I feel it, I can do some “urge surfing.”

                 4)    Watch out now for some “stinking thinking.”

                 5)    One will lead to another so I can’t let myself do it.

                 6)    Some people would like to see me go off of the wagon for their own gain.
                       But, I’m going to disappoint them this time. I can cope.




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             Module 28 Handout: Coping With Urges-Self Statements



                 Coping When Craving Feelings Start to Overwhelm

                 You can feel the craving in your body and your thoughts begin to turn to using.

                 Self talk strategies (Script #3):

                 1)    As long as I keep my cool and use my coping skills, I’m in control.

                 2)    Think of what I want to get out of this. What is my long-term goal.

                 3)    I don’t need to prove myself or test my will power.

                 4)    Remember that this urge will pass quickly, if I do nothing. Remember to breathe
                       and relax.

                 5)    Do the urge surfing now. If it doesn’t work, I can leave the situation.

                 6)    Look for the positive. Don’t assume the worst or jump to conclusions.


                 Coping When It’s All Over


                 Self talk strategies (Script #4)

                 1    These are tempting situations and it will take time for the craving and urges not to
                      come.

                 2 Each time I cope, I get stronger.

                 3 That wasn’t as hard as I thought.

                 4 I’m doing better at this all the time!

                 5 I can be pleased with the progress I’m making.




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                 Adapted from Novaco (1975)




                 Module 28 Handout: Coping With Cravings and Urges


                 Reminder Sheet

                 •    Urges are common in the recovery process. They are not a sign of failure. Instead,
                      try to learn from them about what you’re craving.
                 •    Urges are like ocean waves. They get stronger only to a point, then they start to go
                      away.
                 •    You win every time you defeat an urge by not using. Urges only get stronger if you
                      give in and feed them. An urge will eventually weaken and die if you do not feed it.

                 Practice Exercises

                 For next week, make a daily record of urges to use drugs or drink, the intensity of those
                 urges, and the coping behaviors you used.

                 1.     Fill out the DAILY RECORD OF URGES TO DRINK
                        a.     Date
                        b.     Situation: Include anything about the situation or your thoughts or feelings
                               that seemed to trigger the urge to drink.
                        c.     Intensity of urge or craving: Rate your urge, where 1 = none at
                               all, 100 = worst ever.
                               d. Coping behavior. Use this column to note how you attempted to cope with the urge to
                                drink. If it seems like it would help, note the effectiveness of your coping.




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                 Module 28 Handout: Coping with Cravings and Urges Form

   DAILY RECORD OF URGES TO USE DRUGS OR ALCOHOL

    Date           Situation (include your thoughts    Intensity of Cravings (1-100)   Coping Behaviors Used
                   &feelings)
    5/16/98        Was feeling stressed and worried.        75                         Took a shower. Listened to
                   Had bad phone call home.                                            relaxing music.




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                                           Module 28 Main Points



      Urges are a common part of recovery and do not mean failure.

      Every time that you get past an urge or craving without using is a victory!

      There are four phases to coping with urges:

          o Preparation for the encounter

          o Encountering the situation

          o Dealing with feelings of being overwhelmed

          o Talking to yourself after the situation is over




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                 Module 29 Handout: Relapse Prevention Model Overview

             The Three Main Areas which need to be addressed to prevent relapse:

             • Substance Abuse
             • Criminal Behavior
             • Mental Illness

             These three are all connected; relapse in one area can contribute to relapse in all three areas.

             How did my behavior in one of these three areas contribute to making the other two areas
             worse?____________________________________________________________


             Lifestyle Balance- keeping our shoulds, wants, and needs, and the different areas of our life in
             balance.

             Coping with Life and Sources of Stress Successfully
                   • Healthy Addictions - exercise, meditation, etc.
                   • Dealing with Negative Emotions
                   • Changing our Thinking
                   • Positive Communication
                   • Asking For Help
                   • Dealing with Social Pressure
                   • Dealing with Conflict
                   • Finances/Employment choices
                   • Housing choices

             Abstinence Violation Effect - If we believe that one lapse will automatically lead to a full-blown
             relapse, then it most likely will. If we change this belief, we can keep a lapse from becoming a
             relapse.

             High Risk Situations and Triggers to Relapse: Identifying, Avoiding, and Coping with them

             Cravings and Urges Coping with and managing them.

             Self-Monitoring for early warning signs of relapse

            Seemingly Irrelevant Decisions

             Developing a Recovery Network and a Recovery Plan

             Identifying our Roadblocks to Recovery




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                                         Module 29 Main Points



      Having a solid relapse prevention plan will increase your chances of success.

      Your plan needs to address substance sue, mental health and criminal behavior because all three are
      inter-connected.

      Relapse in one area can lead to relapse in another area.

      Seemingly Irrelevant Decisions (SIDS) can lead us to relapse.

      The Abstinence Volitional Effect (AVE) is when we let one mistake (lapse) turn into a full blown
      relapse.




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                 Module 30 Handout: Dimensions of Lifestyle Balance for Recovery



             On the next two pages are lifestyle dimensions that need to be balanced in order to
             maintain recovery from substance abuse, mental illness, and criminal behavior. In
             parentheses are examples of some needs or activities that need to be taken care of in
             order to maintain balance in these areas.

             Lifestyle balance is not an end state; maintaining balance is an ongoing process
             which takes time, thoughtful planning, effort and help from others. As your
             circumstances change, the right balance for you will most likely change somewhat,
             and balance is going to be different for different people depending on their likes,
             dislikes, abilities, and circumstances.

             Certain things are crucial (‘shoulds’, such as maintaining conditions of release or
             parole), others are more subject to your preferences (‘wants’), such as what kinds of
             positive self-renewal exercises are most enjoyable and uplifting for you. Some things
             may be both shoulds and wants.

             You may need to do certain things daily (such as meditation, prayer, 12-step
             groups) and other things only three times a week (maybe exercise), while others
             are only done as scheduled (parole officer visits). You will need to keep thinking
             about how to maintain balance and trying out different things until you find what
             works for you; this is a lifelong learning process, which is made up of many small
             steps.

             Remember to try to balance shoulds and wants as much as possible so that you
             don’t feel deprived, resentful, and stressed out. If shoulds are too high and wants too
             low, this can lead to a desire for indulgence and escape, impulsive, self-
             destructive behavior, and relapse into substance abuse, mental illness symptoms,
             and/or criminal behavior!
                                                     Activities:

             • Think about how you will balance these competing demands, and write that in
               the space below.

             • Fill out the next page on the best ways to balance your life now.

             • Fill out the third page as you would like to have your life balanced shortly after
                 release. At first after post-release, you may need to focus on how to survive
                 (basic physical/financial needs) without relapsing into substance abuse, criminal

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                 behavior, or mental illness.



                 Module 30 Handout: Dimensions of Lifestyle Balance for Recovery

                                  HOW I WANT TO BALANCE MY LIFE NOW




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                                         Priority
              Lifestyle Dimension        Rate 1-5   “Wants”     “Shoulds” (Musts)




              Basic Survival
              food, shelter, etc


              Substance Abuse
              Recovery 12steps,
              counseling, support
              groups, etc.

              Mental Illness Recovery
              therapy sessions,
              prescribed medications,
              etc.


              Legal Recovery
              parole, probation,
              outstanding courts
              cases, custody, etc.


              Emotional / Social
              family, friends, support
              systems, etc.


              Financial/ Employment
              education, training,
              obtaining job, resume,
              etc.



              Positive Self Renewal
              exercise, meditation,
              church, etc.



              Leisure/ Recreation
              sports, hobbies, self-
              growth, reading, etc.



              Other


                  Module 30 Handout: Dimensions of Lifestyle Balance for Recovery

                          HOW I WANT TO BALANCE MY LIFE SHORTLY AFTER RELEASE

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                                         Priority
              Lifestyle Dimension        Rate 1-5   “Wants”          “Shoulds” (Musts)




              Basic Survival
              food, shelter, etc


              Substance Abuse
              Recovery 12steps,
              counseling, support
              groups, etc.

              Mental Illness Recovery
              therapy sessions,
              prescribed medications,
              etc.


              Legal Recovery
              parole, probation,
              outstanding courts
              cases, custody, etc.


              Emotional / Social
              family, friends, support
              systems, etc.


              Financial/ Employment
              education, training,
              obtaining job, resume,
              etc.



              Positive Self Renewal
              exercise, meditation,
              church, etc.



              Leisure/ Recreation
              sports, hobbies, self-
              growth, reading, etc.



              Other




                                             Module 30 Main Points


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      Life consists of things that we should/must do and things that we want to do.

      A healthy recovery is a balanced recovery.

      Try to keep a balance between wants and shoulds.

      Wants can be used as a way to reward yourself for fulfilling your shoulds.

      Areas of life to keep in balance:

          o Basic Survival

          o Substance Abuse Recovery

          o Mental Health Recovery

          o Legal Recovery

          o Social/ Emotional Relationships

          o Finances and Employment

          o Positive Self-development

          o Leisure Activities




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                 Module 31 Handout: Coping with Stress
             Read through the following list of ways to help cope with stress. Write in additional ways that
             you need to cope with stress in the blanks provided. Circle the items that you need the most work
             on in order to cope with your stress and unpleasant emotions effectively. Fill out your Stress
             Buster plan.

             1) Healthy Lifestyle - A healthy body helps us cope with stress and unpleasant emotions
                a) Eating regular, healthy meals.
                b) Getting enough sleep on a regular schedule.
                c) Staying off drugs and alcohol; Avoiding cigarettes, caffeine, fats, sugars.
                d) Practicing safe sex to avoid catching diseases.
                e) Regular doctor’s visits and taking medications as prescribed.
                f) Others_________________________________________________________


             2) Social Support- Talking to others helps us cope with stress/unpleasant emotions
                a) getting help from others
                b) friends, family, and others who are good for us and care about us.
                c) Going to recovery meetings or other support groups.
                d) Church or spiritual groups help many get social support.
                e) Getting help from doctors, therapists or counselors.
                f) Others__________________________________________________________


             3) Life skills - When we learn specific coping skills to deal with the different parts of our life
                well, we feel better and our problems don’t tend to pile up so much because we keep taking
                care of them a little bit at a time. Some of these are skills that we have been learning in this
                program. Some skills will need to be developed after you are done with this program, so it is
                important to keep on learning better ways to deal with life.
                a) Managing our money and paying our bills
                b) Managing our time to get done what we need to
                c) Job skills
                d) Decision -making and making good lifestyle choices
                e) Relapse prevention
                f) Others__________________________________________________________


             4) Meditation - Regular meditation helps us to deal with negative feelings and reduces anxiety.
                It also allows us to deal better with stress after we have meditated, and be clearer in our
                decision-making. It is also a natural and healthy way to “get high”! Prayer also helps many.

             5) Exercise- Regular exercise, at least two or three times per week, helps us cope with stress, is
                a natural antidepressant, and makes our body able to fight off sickness better. It is also a
                natural and healthy way to “get high”!




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             Module 31 Handout: Coping with Stress
             My Stress Buster Action Plan: The top five things I need to do to cope with stress
             better.


             Remember these are goals to work toward a little at a time. You may only be able to do
             one new thing at a time. That’s fine; put them in order of which healthy habit or new
             skill you want to develop first, and then second, and so on. These are supposed to help
             you, and are not designed to make you feel more stressed!


             1)




             2)




             3)




             4)




             5)




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                                          Module 31 Main Points



      Stress is a natural part of life.

      How you handle stress will impact your recovery.

      Sometimes people try to use drugs and alcohol as a way to cope with stress. This solution always ends
      up leading to more stress in the long run.

      Some healthy ways to deal with stress are:

          o Leading a healthy lifestyle

          o Using social support systems

          o Developing good life skills

          o Meditation

          o Exercise




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             Module 32 Handout: Meditation Exercises


             Benefits of Meditation


             Reduces anxiety and stress, helps decrease other unpleasant emotions.


             Promotes better physical health, helps body fight off diseases and heal.


             Increases clear thinking, creativity and good decision-making even after meditation.


             Helps people who have trouble sleeping get to sleep; helps many people need less sleep.


             Helps you cope better with life after you are done meditating.


             Increases mental alertness and productive energy after meditation.


             A natural, refreshing, healthy way to “get high” and temporarily leave life’s stressful situations
             behind.



             At least once a day, and as needed, perform a meditation exercise for at least
             15-20 minutes each time to calm your mind and body. Be sure to meditate in
             a dark and quiet place, if possible. It is helpful to meditate at the same time
             and place each day, because it becomes a regular habit and it makes it easier
             to meditate each time. Many people like to meditate in the morning, and find
             that they have a calmer attitude and clearer mind throughout the day after
             meditating. Other people like to meditate in the evening, or right before
             bedtime; this can help them fall asleep. Whatever is practical with your daily
             life and works best for you is fine. Sometimes people find that they need to
             meditate extra sessions during the day if they are tired or under a lot of stress.
             Meditating at least once a day increases the benefit. Over time, you can
             gradually meditate for longer periods of time, or more than once a day, to
             increase the benefits of meditation. Below is one example of a meditation
             exercise that includes several different meditation techniques. Use whatever
             meditation techniques work best and are most rejuvenating for you.


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             Module 32 Handout: Meditation Exercises


             1) Sit in an upright, comfortable posture, (or lie down if more comfortable, if
             possible on back, or if not on side), close eyes, and start by taking five slow deep
             breaths, so that the breaths go into first your stomach and then your chest, and let
             them out slowly as well. Hold each breath for a moment, only as long as is
             comfortable.

             2) Let your breathing return to its natural rhythm, and begin to let your body relax.

             3) Visualize yourself in a beautiful, peaceful place in nature, and inhale the
             peaceful atmosphere into all the different parts of your body, starting with your
             toes and moving up, and exhale any stress, tension, worry, or discomfort.

             4) Let yourself be in this beautiful place and enjoy its peace. If distracting feelings
             or thoughts arise, watch them go by like clouds in the sky, sometimes intense,
             sometimes mild, but only temporary thoughts or feelings, that are not who you are.

             5) You can also focus on the space between the breath, or the space between two
             thoughts, or look at or think about the sky, to help your mind calm down.

             6) Throughout the day, if you feel yourself becoming stressed, take some deep
             breaths, and remember the calm, peaceful space of your meditation.


             I realize how important meditation is to my recovery, so I am making a
             commitment to meditate on a daily basis.

             After this program no longer requires me to meditate, my regular daily
             meditation time will be at _____________




             Signature                                                                  Date




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                                          Module 32 Main Points



      Meditation is an excellent way to reduce stress.

      Mediation has several benefits, not the least of which is that it’s FREE!

      To receive the most benefit from meditation, practice it regularly and often.




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             Module 33 Handout: High-Risk Situations


             The Big Three (the most common relapse situations)

             1) Feeling Bad (Unpleasant Feelings) - the most common situation for people to
             relapse is when they feel angry, sad, bored, anxious, stressed, embarrassed, or
             guilty.

             What are the negative emotions that I tended to avoid the most by using? ___________________



             2) Social Pressure - the second most common situation for people to relapse is
             when they are around others who are using. The social pressure can be
             indirect, which is what happens when you are simply around others who are
             using, or the social pressure can be direct, when others offer you a drink or
             drug, and try to encourage you to use it. People might even make fun of you
             for not using.
             Who did I use to use with, and who would be most likely to pressure me to use? _____________




             3) Fights - (or arguments) the third most common situation for people to
             relapse is after they have been in an argument or have been criticized by
             someone else.

             Who did I use fight or argue with before using? What kinds of conflicts contributed to me using
             in the past? ____________________________________________________________________



             There are other relapse situations that are not quite so common as the ‘Big
             Three’. Write personal examples of using next to these relapse situations.
             Pleasant Feelings - using substances to “celebrate” or try to get more of a good feeling.

             Urges and Cravings - having a sudden strong desire to use.

             Testing Personal Control - when people try using to see if they can now control their use, or
             “handle” it this time.

             Feeling Bad Physically - when people try to make their physical pain or discomfort less through
             using.
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             Module 33 Handout: High-Risk Situations




             Things to keep in mind when identifying my high risk situations:


             What places and social situations did I use in the most?




             What were the times of the day or week that I tended to use?




             What people, or kinds of people, did I use with the most?




             What things did I use to get high (drug paraphernalia, alcohol containers, etc.)?




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                                          Module 33 Main Points



      There are some situations that are more likely to lead to relapse than others.

      Three common situations are:

          o Feeling Bad

          o Social Pressures

          o Fights

      Questions to answer about your past high risk situations that can help you plan to avoid relapse:

          o Where did I use?

          o Who did I use with?

          o When did I use?




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             Module 34 Handout: ABC Chain

                    Antecedent                      Behavior                       Consequence

                                                                                   Joe felt lonely and bored on
                                                                                   Saturday morning and
                    1.Joe missed his counseling     Joe did not plan his           thought about visiting his
                    session during the week.        weekend                        old friend.
                    2. Joe rationalizes his visit
                    to the old neighborhood by                                     Joe manages to not buy
                    telling himself that he needs   Joe walks through the old      drugs from the dealers and
                    to get toothpaste there.        neighborhood.                  buys toothpaste.
                                                    He decides to knock on his
                    3. Joe feels overconfident      old friend's door to brag      Joe enters the apartment
                    about not buying from the       about how ell he is doing in   where a drug party is going
                    dealers.                        recovery.                      on.
                                                                                   Joe feels good for a
                    4. Joe gets offered drugs                                      moment. Then he feels
                    and feels that he now has it                                   really bad about using and
                    under control and can stop                                     wants more of the drug to
                    after just one.                 Joe takes one hit.             try to feel better.
                    5. Joe feels bad about                                         Joe "crashes" and feels
                    using.                          Joe takes more drugs.          terrible.
                    6. The drugs and money
                    run out and friends invite      Joe goes with his friends
                    him to help them get more       and ends up ribbing a          Joe is arrested and sent to
                    money for drugs.                convenience store.             prison.




             1. How did Joe set himself up for relapse?



             2. What were some Seemingly Irrelevant Decisions (SID’s) that he tricked himself into
             making? How did he rationalize these decisions?


             3. What were some errors in thinking that led him to relapse?



             4. For each of numbers 1-6, what positive behaviors could he have done instead to keep
             himself from relapsing?




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             Module 34 Handout: ABC Chain


                    Antecedent               Behavior                Consequence




                                                                     .




             1. How did you set yourself up for relapse?


             2. What were some Seemingly Irrelevant Decisions that you tricked yourself into
             making? How did you rationalize these decisions?



             3. What were some errors in thinking that led you to relapse?


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             4. For each of numbers 1-6, what positive behaviors could you have done instead to
             keep yourself from relapsing?



                                          Module 34 Main Points



      Relapse doesn’t “just happen”. There are a series of decisions that lead to it.

      To prevent future relapse, it helps to look at past relapses and the thought chains that led to
      using again.

      Often, there are many points among the path to relapse where a different, positive choice could
      have been made that would have prevented relapse.




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             Module 35 Handout: Early Warning Signs for Substance Abuse
             Relapse


             Read through the following common Early Warning Signs for Substance
             Abuse Relapse.

                       If you have had other Early Warning Signs that are not on the list, write
                       those in on the blank lines after the word “other” in the right category. If
                       you add them in, make them as specific as possible as to what your Early
                       Warning Signs were.

                       Circle the ones you have experienced in the past that happened before
                       and during your relapse into substance abuse.

                       Put a check mark next to those that you have experienced recently
                       during your stay here.

             1) Attitude and Thinking changes

                 a) Losing interest in your recovery plan
                 b) Thinking that you can use some alcohol or drugs and stay in control
                 c) Urges and impulses to use drugs or alcohol
                 d) Remembering only the pleasurable part of addiction, and forgetting about
                    the pain
                 e) Making Seemingly Irrelevant Decisions that put you in high risk situations
                 f) Not caring about yourself and what happens in your life
                 g) Other___________________________________________________
                 h) Other___________________________________________________


             2) Mood or Emotional changes
                a) Feeling sad, depressed, or hopeless- feeling like giving up
                b) Becoming too energetic, excited and feeling “on top of the world”
                c) Feeling anxious, nervous, restless or on edge
                d) Feeling bored, empty, or lonely
                e) Feeling lost, aimless, or without any direction
                f) Feeling angry and hating other people
                g) Feeling distrustful and suspicious of others
                h) Feeling negative, cynical, or pessimistic
                i) Other___________________________________________________
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                 j) Other___________________________________________________


             Module 35 Handout: Early Warning Signs for Substance Abuse Relapse


             3) Behavior Changes

                 a) Cutting down or stopping AA, NA, dual recovery, or other support group
                    meetings
                 b) Cutting down or stopping regular contact with your sponsor or recovery
                    group
                 c) Missing counseling appointments without calling in
                 d) Missing other appointments or work without calling in
                 e) Withdrawing from other people and keeping to yourself
                 f) Arguing and getting into fights more with others
                 g) Putting yourself in high risk situations, where there is pressure to use
                 h) Stopping exercise or meditation program, stopping healthy hobbies
                 i) Other___________________________________________________
                 j) Other___________________________________________________


             4) Changes in Daily Living or Physical Changes

                 a) Trouble falling asleep or staying asleep; starting to sleep too much
                 b) Changes in appetite; weight loss or weight gain
                 c) Change in personal hygiene habits (stop showering, brushing teeth, shaving,
                    etc.)
                 d) Changes in energy level (much higher or lower than usual)
                 e) Other___________________________________________________
                 f) Other___________________________________________________




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                                         Module 35 Main Points



      There are early warning signs before a substance abuse relapse occurs.

      If you know your personal warning signs, it is easier to avoid relapse.

      Some common types of warning signs include:

          o Attitude and Thinking Changes

          o Mood or Emotional Changes

          o Behavioral Changes

          o Changes in Daily Living or Physical Changes




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             Module 36 Handout: Relapse Set-Ups


             1. Lifestyle imbalance


             2. Desire for indulgence


             3. Urges and impulses to go off medication or neglect mental health
                needs, do substances, and/or commit crimes


             4. Rationalization and denial


             5. The Seemingly Irrelevant Decision(s)—(SIDs)


             6. Exposure to high-risk situations




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             Adapted from Marlatt, G.A., & Gordon, J.R., Relapse Prevention. New York: Guilford Press, 1985.




                                                  Module 36 Main Points



      Relapse is due to a series of small decisions that happen much earlier, which lead the person into a
      relapse “trap.”

      A “relapse trap” is a situation that is destined to result in a relapse unless strong action is taken.

      Common relapse traps:

          o Lifestyle imbalance

          o Desire for indulgence

          o Urges and impulses to go off medication or neglect mental health needs, do substances,
            and/or commit crimes

          o Rationalization and denial

          o The Seemingly Irrelevant Decision(s)—(SIDs)

          o Exposure to high-risk situations




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             Module 37 Handout: Life Goals
             LIFE GOALS

             Imagine how you want your life to be five years from now with regard to work, play,
             relationships with others, and your relationship to yourself. Now, think of the small goals that
             you will need to achieve to make these life goals come true. For example: If you see yourself
             working as a computer specialist five years from now, your goals might be: 1) Earn my GED; 2)
             Attend technical school to learn basic computer skills; 3) Take an entry-level position to gain
             computer programming experience; and 4) Work for a top computer software company.


             A. Marriage and/or Family Goals: How would you like to develop or strengthen your family
                relationships? Include sharing of activities and the development of closeness.

                 1. ______________________________              2. _____________________________

                 3. ______________________________              4. _____________________________

                 5. ______________________________              6. _____________________________

                 7. ______________________________              8. _____________________________

             B. School and Work Goals: What are your school, work, and job objectives, both short-term
                and long-term?

                 1. ______________________________              2. _____________________________

                 3. ______________________________              4. _____________________________

                 5. ______________________________              6. _____________________________

                 7. ______________________________              8. _____________________________

             C. Social and Friendship Goals: What are your goals with regard to friends and social
                activities? What groups or clubs or other organizations do you want to be part of?

                 1. ______________________________              2. _____________________________

                 3. ______________________________              4. _____________________________

                 5. ______________________________              6. _____________________________

                 7. ______________________________              8. _____________________________




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             Module 37 Handout: Life Goals


             D. Leisure Time and Recreation Goals: What do you want to do with your free time?        What
                hobbies, sports, or interests do you want to develop?

                 1. ______________________________               2. _____________________________

                 3. ______________________________               4. _____________________________

                 5. ______________________________               6. _____________________________

                 7. ______________________________               8. _____________________________

             E. Personal Development Goals: What new attributes do you want to develop in yourself?
                Strengthen? Decrease?

                 1. ______________________________               2. _____________________________

                 3. ______________________________               4. _____________________________

                 5. ______________________________               6. _____________________________

                 7. ______________________________               8. _____________________________

             F. Spiritual Goals: What would you like to see happen with your spiritual life?

                 1. ______________________________               2. _____________________________

                 3. ______________________________               4. _____________________________

                 5. ______________________________               6. _____________________________

                 7. ______________________________               8. _____________________________

             G. Emotional Goals: What emotions do you want to handle better? What feelings do you want
                to feel more? Feel less?

                 1. ______________________________               2. _____________________________

                 3. ______________________________               4. _____________________________

                 5. ______________________________               6. _____________________________

                 7. ______________________________               8. _____________________________

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                                          Module 37 Main Points



      Having goals is a vital part of a healthy recovery.

      Without goals, people begin to get bored and feel that life is pointless. This can lead to relapse.

      You should have goals in a variety of categories including:

          o Marriage and/or Family

          o School and Work

          o Social and Friendship

          o Leisure Time and Recreation

          o Personal Development

          o Spiritual

          o Emotional




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             Module 38 Handout: Top Early Warning Signs

             THE WARNING SIGNS FOR RELAPSE OF MENTAL HEALTH DISORDER SYMPTOMS




             1. Attitudinal and Thought Changes

                    a. Losing interest in your treatment plan
                    b. Thinking that counseling and/or medication is not needed anymore
                    c. Not caring about yourself and what happens in your life
                    d. Thinking of hurting yourself or someone else
                    e. SIDs



             2. Mood or Emotional Changes

                    a. Sad or depressed
                    b. Energetic, excited, on top of the world
                    c. Anxious, nervous, on edge
                    d. Bored, restless, or empty
                    e. Angry and hate other people
                    f. Distrustful, suspicious of others



             3. Behavioral Changes

                    a. Cutting down on medication without discussion with therapist or doctor
                    b. Withdrawing from other people and keeping to yourself
                    c. Arguing more with others
                    d. Missing therapy appointments


             4. Changes in Daily Living

                    a. Trouble falling asleep or staying asleep
                    b. Change in personal hygiene habits
                    c. Big change in energy level (much higher or lower than usual)


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             Module 38 Handout: Relapse Story-Part1

             RELAPSE STORY GUIDELINES -
             MENTAL HEALTH DISORDER SYMPTOMS (Part 1)




             1. The last time my mental health was stable was:



             2. The things that I did to help myself be stable were:



             3. The things in the chain that caused me to relapse were:



             4. The first change that happened was:



             5. I stopped or cut back on my medication because I thought:



             6. Where did it lead?




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                                         Module 38 Main Points



      There are early warning signs before a mental health relapse occurs.

      If you know your personal warning signs, it is easier to avoid relapse.

      Some common types of warning signs include:

          o Attitude and Thinking Changes

          o Mood or Emotional Changes

          o Behavioral Changes

          o Changes in Daily Living or Physical Changes




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             Module 39 Handout: Relapse Story-Part 2

             RELAPSE STORY GUIDELINES -
             MENTAL HEALTH DISORDER SYMPTOMS (Part 2)




             1. I recognized the first early warning sign:




             2. I identified my situation as high-risk:




             3. I coped with the situation by:




             4. The things that I learned about this situation were:




             5. I rewarded myself for having coped successfully by:




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                                          Module 39 Main Points



      Looking at past relapses is a good way to learn what not to do.

      You should also anticipate new situations

      It is important to “rehearse” potential relapse situations. By thinking about potential situations and
      deciding on plan of action BEFORE you encounter these situations, you are more likely to make
      correct and safe decisions.




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             Module 40 Handout: Top Early Warning Signs
             THE TOP WARNING SIGNS
             FOR RELAPSE INTO CRIMINAL BEHAVIOR

             1. Attitudinal and Thought Changes
                    a. Losing interest in your recovery plan
                    b. Thinking of ways that you can take advantage of others or break the law
                    c. Not caring about yourself and what happens in your life
                    d. Believing that your troubles are over
                    e. Believing “just this time”
                    f. SIDs

             2.     Mood or Emotional Changes
                    a. Sad or depressed
                    b. Energetic, excited, on top of the world
                    c. Anxious, nervous, on edge
                    d. Bored, restless, or empty
                    e. Angry and hate other people
                    f. Distrustful, suspicious of others
                    g. Lonely
                    h. Bitter

             3.      Behavioral changes
                     a. Cutting down or stopping AA, NA, dual recovery, or support group
                    b. Cutting down/ stopping regular contact with your sponsor or support group
                    c. Withdrawing from people and keeping to yourself
                    d. Arguing more with others
                    e. Missing therapy appointments
                    f. Cutting down or stopping hobbies and enjoyable activities
                    g. Placing yourself in situations where there is pressure to break the law
                    h. Withdrawing from people and keeping to yourself
                    i. Getting involved in petty crimes
                    j. Avoiding responsibility
                    k. Feeling entitled

             4.     Changes in daily living
                    a. Sleeping a lot less or more than usual
                    b. Change in personal hygiene habits
                    c. Big change in regular routines for the day or week




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             Module 40 Handout: Relapse Story-Part 1

             RELAPSE STORY GUIDELINES -
             CRIMINAL BEHAVIOR (Part 1)




             1. My most recent attempt to stop doing criminal behavior was:



             2. The things that I did to help stay away from criminal behavior
                were:



             3. The things in the chain that caused me to go back to criminal
                behavior were:



             4. The first change that happened was:



             5. I conned myself that things were okay by thinking:



             6. Where did it lead?




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                                         Module 40 Main Points



      Just like with substance abuse and mental illness, there are early warning signs before a criminal
      behavior relapse occurs.

      If you know your personal warning signs, it is easier to avoid relapse.

      Some common types of warning signs include:

          o Attitude and Thinking Changes

          o Mood or Emotional Changes

          o Behavioral Changes

          o Changes in Daily Living




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                 Module 41 Handout: Relapse Story-Part 2


             RELAPSE STORY GUIDELINES -
             CRIMINAL BEHAVIOR (Part 2)




             1. I recognized the first early warning sign:




             2. I identified my situation as high-risk:




             3. I coped with the situation by:




             4. The things that I learned about this situation were:




             5. I rewarded myself for having coped successfully by:




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                                          Module 41 Main Points



      Looking at past relapses is a good way to learn what not to do.

      You should also anticipate new situations

      It is important to “rehearse” potential relapse situations. By thinking about potential situations and
      deciding on plan of action BEFORE you encounter these situations, you are more likely to make
      correct and safe decisions.

      Criminal thinking errors need to be challenged.

      Just like other relapses, relapse into criminal behavior starts with “small” things. Things like lying
      about why you are late for work, eating your roommate’s food without permission, etc…

      Learning how to be “a more successful criminal” from your cellmate is not a wise choice. After all,
      he is sitting right next to you, isn’t he? How “successful” was he?




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               Module 42 Handout: Triggers, Cravings, Urges
             Definitions

             • Cravings - desire to use alcohol or drugs, usually felt in the body
             • Urges - feelings and thoughts associated with wanting to do something
               destructive
             • Triggers - things that remind you of old destructive behaviors and bring up
               cravings and urges

                                        Types of Cravings and Urges

             • Substance Abuse related - feeling an impulse to get high or drink alcohol

             • Criminal - feeling an impulse to engage in criminal behaviors

             • Other Destructive Behaviors - wanting to stop medications for mental
               disorders, wanting to stop counseling, wanting to have unprotected sex, etc.

                                      Types of Triggers and Examples

             • External Triggers - from our external environment or situation; come through
               our 5 senses, something that reminds us of our old destructive behavior

                   Sight - driving past a bar, past the old neighborhood where you used to use
                    or commit crimes, the sight of others using or high, drug paraphernalia
                    (pipes, bottles, needles, etc.)

                   Smell - smelling alcohol or drugs, marijuana smoke, smell of old
                    neighborhood or bar

                   Hearing - the sound of a beer bottle opening, the sound of a drug or crime
                   associate’s voice on the phone, the sounds of people at a party, certain music you
                   used to listen to when you got high, someone telling a “war story” about
                   drugs/crimes

                   Taste - taste of a food or drink that you used to have when getting high or
                    drunk, such as coffee, a certain soda, or “munchies” food


                   Touch - the feeling of hugging someone you used to get high and have sex
                    with, the feeling of touching something that is like drug paraphernalia
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                    (pipes, bottles, needles, etc.)



               Module 42 Handout: Triggers, Cravings, Urges


             • Internal Triggers

                   Thoughts - remembering what it used to feel like to use, “glorifying” the old
                    days, only thinking about the pleasurable part of substance abuse, wishing
                    you could escape from everyday pressures, thinking “it’s not fair that I can’t
                    use, all of my old friends do”, rationalizing - “one won’t hurt”,
                    overconfidence - “I can handle it this time”, “I’m over this”, etc.

                   Feelings - negative feelings that you used to react to by using, such as
                   sadness, loneliness, depression, boredom, anger, anxiety or fear, stress,
                   shame, guilt, feeling bad about yourself, etc. Wanting some “excitement”, like
                   the rush you might have felt when performing a crime. Feelings
                   brought up by a drug or crime dream. Positive feelings and wanting to
                   “celebrate” them by using. Feelings brought up by social pressure or
                   conflict in relationships.




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                                          Module 42 Main Points



      Cravings = desire to use alcohol or drugs, usually felt in the body

      Urges = feelings and thoughts associated with wanting to do something destructive

      Triggers = things that remind you of old destructive behaviors and bring up cravings and urges

      External triggers are things outside of you that trigger you-sounds, sights, smells, tastes and touches

      Internal triggers occur inside you- thoughts and feelings




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               Module 43 Handout: Coping with Triggers, Cravings and Urges


             Remember: the first line of defense against cravings and urges is avoiding the
             triggers and high risk situations that give rise to them! Don’t go into that old
             neighborhood where you used to use or commit crimes, avoid bars, don’t keep any
             alcohol or drug paraphernalia around you, avoid interacting with people who are
             still using, don’t go to parties where people use, etc.

             Even if you do your best to avoid external triggers, some cravings and urges will
             still arise. Do your best to avoid your triggers, but be prepared to come across
             unexpected triggers. Even if you avoid all external triggers, you can still have
             internal triggers, such as thoughts, feelings, or memories, that can bring up
             cravings and urges.

             Cravings and urges are a normal part of recovery. Everyone in recovery
             experiences these at times. You don’t need to feel bad about yourself or your
             recovery just because you have a craving or urge. The important thing is to be
             aware of them and decide on an active coping strategy so that you can stop
             yourself from giving in to them.

             Cravings and urges grow weaker the longer you “starve” them. Giving in to them
             makes them stronger! Over time, as you maintain your recovery,
             cravings and urges will continue to get less and less, as long as you don’t give in to
             them. Giving in to cravings and urges may decrease the unpleasant
             sensations associated with them for a short time, but giving in to them only makes
             them stronger the next time!

             Coping Strategies: What to do when Cravings and Urges Arise

             Try out different coping strategies from the list below and see what works best
             for you. Practice them ahead of time so that you are prepared and know what
             to do when an urge does arise. When an urge does arise, keep trying different
             ones until one works, you may need to use different ones at different times.
             Underline those that work best for you, and write out others that work well
             for you that are not on this list (on bottom of second page, or on back of page).
             After release, keep these two pages with you in your wallet to refer to in an
             emergency.




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               Module 43 Handout: Coping with Triggers, Cravings and Urges

             Distraction - Do something else that is not a trigger, such as reading, exercise,
             take a shower, hobbies or sports, take a fast 10 min walk (only in a non-
             trigger neighborhood!) watching TV (be careful of beer commercials or
             shows/movies that glamorize drug or alcohol use or crime, maybe only watch
             PBS).

             Talking - Call or talk to a trusted friend who is a positive person and does not
             use or commit crimes, or call a counselor or sponsor. Ask for help. Talking
             about your urge may help you to get over it. Ask the person to let you talk about
             your reasons for not giving in to the urge, and ask them to remind you of the
             consequences of your behavior.

             Consequences - Remind yourself of your reasons for not giving in, and the
             good consequences of not giving in (staying out of incarceration, feeling good
             about yourself, making the urge get weaker the next time, etc.), as well as the
             possible bad consequences of giving in (incarceration, death, making the urge
             stronger next time, could lead to full relapse).

             Substitution - Instead of giving in to the urge, substitute a pleasant activity that
             is not harmful and is not one of your triggers, such as receiving a
             massage, giving yourself a massage, eating or drinking something you enjoy,
             chew gum, hard candy, etc.

             Wait it out - Remember that most cravings and urges only last for a few
             minutes, and simply wait it out.

             Urge Surfing - Use “urge surfing” by watching the urge and noticing it, and
             detaching yourself from it by realizing that it is not you, you don’t have to act on
             it, and it will decrease soon.

             Remove yourself from the situation that brought on the craving; leave the
             party or neighborhood, retreat to a safe drug free place. One way to do this
             temporarily in work or social situations is to excuse yourself to go to the
             bathroom.

             Self talk - Tell yourself positive messages, “This will be over soon”; “I can do
             this”, “I can get help if I need it”; “I don’t have to give in to this”, etc.

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             Get Angry and Fight with Your Urge - Fight against the urge like the enemy it is,
             and tell it; “Go to hell, I won’t let you trick me into hurting myself and ruining
             my life anymore” or similar statements.


               Module 43 Handout: Coping with Triggers, Cravings and Urges


             Support Groups - Go to a 12-step meeting or other support group. Being with
             others in recovery can help you to remember that you can get through this. Get
             other people’s names and numbers to call in case of future cravings and urges.
             Keep trying to get a positive person to be a temporary sponsor, and try to
             eventually get a long-term sponsor. Develop a positive social network of people to
             spend time with that don’t use or commit crimes.

             Breathe - Take 10 - 20 slow, deep breaths; the urge may be gone after only a few
             minutes of this. If it is not, then keep going with breathing and use urge surfing,
             meditation, prayer, visualization, or positive self - talk; whatever
             works for you!

             Meditation - meditating regularly will make that a pleasant, positive addiction and
             give you a natural, beneficial “high”. Then when you have an urge, you can
             meditate instead of using.

             Visualize the positive consequences of not giving in to the urge and the
             negative consequences of giving in to the urge. See what it would be like to be
             rearrested, feel how you would feel having to go back to prison. Now visualize how
             much stronger you will feel if you don’t give in to the urge, and how you will be
             happier in the long run.

             Pray - ask for help from your Higher Power.

             Reward yourself with something pleasant and not harmful when you have
             successfully resisted the urge. Give yourself some praise, and tell yourself
             “Good Job!”

             Others - write out other specific coping strategies not in this list, especially
             ones that work well for you (such as what kind of exercise, sports, reading,
             food, or hobbies help). You can also use the bottom of this page for this.




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                                         Module 43 Main Points



      Cravings and urges are a natural part of recovery.

      The more that you starve, the weaker they become.

      There are many different coping mechanisms to deal with urges and cravings. You may have to try
      several to find out what works best for you.

      You want to have several different coping mechanisms in your “toolbox” because you may not
      always be able to use your first choice.




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               Module 44 Handout: What to do if I Lapse-Emergency Plan


             Keep this handout with you in case of an emergency!

             So you have lapsed; that means that you have had a slip into a small episode
             of substance use, or criminal behavior, or have been neglecting your mental
             health needs which has caused your mental illness symptoms to increase.

             Steps I will take to prevent a full-blown relapse
             Remember not to let yourself be tricked by the Abstinence Violation Effect.
             The Abstinence Violation Effect is a mistaken belief that once you have had a
             lapse, you are automatically going to return to a full-blown relapse. This
             mistaken belief can lead to feelings of guilt, anger at oneself, or giving up, and
             can lead to a full-blown relapse. Instead, forgive yourself and get back on
             track as soon as possible by following your plan below. Learn from your
             lapse.


             First, identify which kind of lapse you have had: a Substance Lapse, a Criminal
             Lapse, or a Mental Health Lapse; it could be more than one; then follow the
             coping steps listed under those kinds of lapses.




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               Module 44 Handout: What to do if I Lapse-Emergency Plan
             Substance Lapse
             1) I will remove myself from any high-risk situations as quickly as possible and get to a safe
                place.

             2) I will keep calling people from my recovery network until I find someone who can help me
                get back on track.

                            Names and numbers of 3 people to call if I have this type of lapse

                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________


             3) Other specific steps I can take to keep this from becoming a full-blown relapse.

             Criminal Lapse
             1) I will remove myself from any high-risk situations as quickly as possible and get to a safe
             place.

             2) I will keep calling people from my recovery network until I find someone who can help me
                get back on track.

                            Names and numbers of 3 people to call if I have this type of lapse

                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________

             3) Other specific steps I can take to keep this from becoming a full-blown relapse.


             Mental Health Lapse

             1) I will remove myself from any high-risk situations as quickly as possible and get to a safe
                 place. This might mean taking myself to a hospital Emergency Room for medication and
                 stabilization.
             2) I will keep calling people from my recovery network until I find someone who can help me
                 get back on track.

                            Names and numbers of 3 people to call if I have this type of lapse

                    Name____________________ Phone number _________________
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                    Name____________________ Phone number _________________
                    Name____________________ Phone number _________________

             3) Other specific steps I can take to keep this from becoming a full-blown relapse.


               Module 44 Handout: What to do if I Lapse-Emergency Plan


             Questions to answer when developing your emergency plan:

             1) What is a safe place for me to go to? (It should be in a place where no one does drugs or
                commits crimes, and not one of my high-risk situations or triggers. Maybe it is a 12-step or
                other support group.)_________________________________________________________



             2) What mental illness or substance abuse symptoms are signals that I should go to the hospital
              emergency room?____________________________________________________________




             3) Is there some way I can undo whatever criminal behavior I have committed? Who can best
                help me to overcome what I have done and get back on track?_________________________



             4) How can I overcome the Abstinence Violation Effect, and not fall into the mistake that I have
                to have a full-blown relapse? __________________________________________________



             5) How can I forgive myself quickly so that guilt, anger, depression or other strong emotions
                don’t contribute to me having a full-blown relapse?_________________________________



             6) Other coping ideas___________________________________________________________




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                                           Module 44 Main Points



      Both lapses and relapse can occur in recovery.

       A lapse is when you have had a slip into a small episode of substance use, or criminal behavior,or
      have been neglecting your mental health needs which has caused your mental illness symptoms to
      increase.

      A relapse is when you let the one small mistake completely derail you off the healthy lifestyle track.

      Though it is best to not have either, don’t turn a lapse into a full relapse.

      The Abstinence Volitional Effect (AVE) is a mistaken belief that once you have had a
      lapse, you are automatically going to return to a full-blown relapse. This is not true, unless you
      make the choice to make it true.

      BUT- your ultimate goal should be to have neither lapses nor relapses. Lapses are very dangerous
      territory to be in. If you do lapse, immediately reach out to your support system.




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             Module 45 Handout: Developing a Recovery Network


             Who should be in my Recovery Network? Add in names of people who could
             be helpful to you in recovery in as many categories below as possible.
             Remember to only choose people who do not use alcohol or drugs, do not
             engage in criminal behavior, and will be helpful and supportive of you in your
             recovery from substance abuse, criminal behavior, and mental illness.

              People from 12-step and other support groups:


              People where you live or near where you live:


              Treatment professionals (counselors, case managers, doctors, etc.):


              Criminal Justice professionals (such as probation or parole officers, or case managers):


              People from church or other spiritual organizations:


              Family:


              Friends:


             Who is missing from the above list that should be here?


             What steps could you take to get these people involved in your recovery?


             What should you tell the above people to educate them about your recovery?


             How can you ask them to assist you in recovery?



             Hint: One good strategy is to attend 12-step and other support groups regularly and get names and phone numbers of
             people on a regular basis who you think could be helpful to your recovery. Ask for a temporary recovery sponsor ASAP
             and then get a long term one.



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                                          Module 45 Main Points



      Your social and personal relationships can make or break your recovery.

      Healthy, clean and sober, pro-social people will help it.

      Unhealthy people will harm it.

      It is critical to develop a good support system.

      There is an old proverb that says, “Show me who your friends are, and I will show you who you are.”




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                                          RELAPSE PREVENTION PLAN


                  Goals, Time Management, and Lifestyle Balance

                    a) What are my life goals that will help me maintain my recovery after release?
                       What steps am I going to take to work toward achieving my goals?




                    b) How do I plan to live a balanced lifestyle to maintain my recovery? What areas of
                       my life do I want to balance?




                    c) How do I plan to manage my time after my release? What daily/weekly activities
                       am I going to do to maintain my recovery, and how often?




                 Coping with Stress-What positive activities will I do to cope with stress?




                 My past Seemingly Irrelevant Decisions that could set me up for relapse,
                 and how to avoid them in the future:




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                                            RELAPSE PREVENTION PLAN



                 Early Warning Signs
                    a) My early warning signs for relapse into substance abuse:




                    b) What will I do to avoid relapse when I notice these warning signs?




                    c) My early warning signs for relapse into mental illness:




                    d) What will I do to avoid relapse when I notice these warning signs?




                    e) My early warning signs for relapse into criminal behavior:




                    f) What will I do to avoid relapse when I notice these warning signs?




                 Managing Cravings and Urges

                    a) What things trigger my cravings/urges to relapse or commit crimes? How can I
                       avoid those triggers?




                    b) Which techniques work best for me to manage my cravings/urges when they
                       arise?


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                                           RELAPSE PREVENTION PLAN



                 My Emergency Plan to prevent a lapse from becoming a full-blown relapse?




                 Coping with high-risk situations for relapse into substance abuse or criminal acts:

                    a) What are my personal high-risk situations for relapse? How do I plan to avoid
                       them and cope with them?




                    b) How do I plan to cope with Feeling Bad so that I do not relapse?




                    c) How do I plan to resist Social Pressure to use drugs/alcohol or commit crimes




                    d) Coping with Conflict:

                       i) How do I plan to change my thinking to cope with conflict and not relapse?




                       ii) How do I plan to communicate more effectively to cope with conflict?




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                                            RELAPSE PREVENTION PLAN


                  Avoiding Future Incarceration
                    a) Errors in Thinking



                       i) My main thinking errors that led to me committing crimes & going to prison:




                       ii) My main positive thoughts with which I will replace my thinking errors:




                    b) What will I do differently to make sure I don’t go back to prison?




                 How do I plan to maintain treatment for my mental health, substance
                 abuse, and physical health needs after release?




                 What is my housing plan for after I am released?




                  What is my employment plan for after I am released?



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                 How do I plan to develop a recovery network after I am released?




                                          Module 46 Main Points



      A well thought out and complete Relapse Prevention Plan is critical to your recovery.

      You should share your plan with the important people in your life- spouse, parents, parole officer, etc..

      A Relapse Prevention Plan needs to be revisited and modified on a regular basis.




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             Module 47 Handout: Payoff Matrix-- Directions


                               Advantages/Benefits               Advantages/Benefits
                            What are the benefits/payoffs        What are the benefits/
                            of using drugs and alcohol?        payoffs of being clean and
                            What do you gain by using?        sober? What do you gain by
                                                                       not using?




                             Disadvantages/ Losses             Disadvantages/ Losses
                                   What are the                What are the negatives/
                            negatives/downside of using       downside of staying clean
                            drugs and alcohol? What do       and sober? What do you lose
                                you lose by using?                  by not using?




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                 Module 47 Handout: Payoff Matrix Substance Abuse


                 The Behavior: Using drugs and alcohol.

                                Advantages/Benefits           Advantages/Benefits
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15
                               Disadvantages/ Losses         Disadvantages/ Losses
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15




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                 Module 47 Handout: Payoff Matrix Mental Illness


                 The Behavior: Not following my treatment plan- not attending counseling or taking
                 medications.

                                Advantages/Benefits           Advantages/Benefits
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15
                               Disadvantages/ Losses         Disadvantages/ Losses
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15




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                 Module 47 Handout: Payoff Matrix Criminal Thinking


                 The Behavior: Breaking the law/ not following rules to get my “needs” met.

                                Advantages/Benefits           Advantages/Benefits
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15
                               Disadvantages/ Losses         Disadvantages/ Losses
                             1                          1
                             2                          2
                             3                          3
                             4                          4
                             5                          5
                             6                          6
                             7                          7
                             8                          8
                             9                          9
                             10                         10
                             11                         11
                             12                         12
                             13                         13
                             14                         14
                             15                         15




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                                         Module 47 Main Points



      Before you engage in a behavior or make a decision, you should weigh the positives and negatives.

      It is important to be honest about both or you might artificially “weight” your decision.

      It is vital that you acknowledge that there are some positives to drug use, criminal behavior and
      mental illness. By acknowledging the “good” parts you can figure out ways to achieve these without
      the negatives associated with relapse. For instance, if you like the fact that substance abuse reduces
      you stress (in the moment) then you can find other, healthy and long term ways to reduce your stress.
      Ways that do not also include negatives.




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                 Module 48 Handout: Values Clarification Survey



                 DIRECTIONS: Circle the number preceding one of the two choices in each category. You
                 must choose one number in each pair of items.

                 1      To be reasonably sure about the future for my family and myself.

                 12    To do things well.
                 ______________________________________________________________________

                 3      To have people think well of me.

                 5     To have as much freedom as possible to do the things I want to do.
                 ______________________________________________________________________

                 11     To have as many good things as possible.

                 12    To do things well.
                 ______________________________________________________________________

                 6      To do new and different things often.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 7      To have friends.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 6      To do new and different things often.

                 8     To create an atmosphere that makes for satisfying family living.
                 ______________________________________________________________________

                 3      To have people think well of me.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________




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                 Module 48 Handout: Values Clarification Survey

                 8     To create an atmosphere that makes for satisfying family living.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 10    To have things neat, orderly and organized.

                 12    To do things well.
                 ______________________________________________________________________

                 2     To have influence with people.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 2     To have influence with people.

                 12    To do things well.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 12    To do things well.
                 _____________________________________________________________________

                 4     To do things for my family and others.

                 7     To have friends.
                 ______________________________________________________________________

                 5     To have as much freedom as possible to do things that I want to do.

Attachment #8                                              171
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                 8     To create an atmosphere that makes for satisfying family living.
                 ______________________________________________________________________




                 Module 48 Handout: Values Clarification Survey


                 2     To have influence with people.

                 3     To have people think well of me.
                 ______________________________________________________________________

                 7     To have friends.

                 8     To create an atmosphere that makes for satisfying family living.
                 _____________________________________________________________________

                 5     To have as much freedom as possible to do the things I want to do

                 12    To do things well.
                 ______________________________________________________________________

                 3     To have people think well of me.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 6     To do new and different things often.

                 12    To do things well.
                 ____________________________________________________________________

                 9     To do what is right according to my beliefs.

                 12    To do things well.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 3     To have people think well of me.

                 8     To create an atmosphere that makes for satisfying family living.
                 ______________________________________________________________________


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                 Module 48 Handout: Values Clarification Survey

                 5     To have as much freedom as possible to do things I want to do.

                 6     To do new and different things often.
                 ______________________________________________________________________

                 6     To do new and different things often.

                 10    To have things neat, orderly and organized.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 5     To have as much freedom as possible to do things I want to do.
                 ______________________________________________________________________

                 3     To have people think well of me.

                 6     To do new and different things often.
                 ______________________________________________________________________

                 5     To have as much freedom as possible to do things I want to do.

                 7     To have friends.
                 ______________________________________________________________________

                 10    To have things neat, orderly and organized.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 2     To have influence with people.

                 4     To do things for my family and others.
                 ______________________________________________________________________

                 8     To create an atmosphere that makes for satisfying family living.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

Attachment #8                                              173
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                 8     To create an atmosphere that makes for satisfying family living.
                 12    To do things well.
                  ______________________________________________________________________




                 Module 48 Handout: Values Clarification Survey

                 4     To do things for my family and others.

                 5     To have as much freedom as possible to do things I want to do.
                 ______________________________________________________________________

                 9     To do what is right according to my beliefs.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 2     To have influence with people.
                 ______________________________________________________________________

                 9     To do what is right according to my beliefs.

                 10    To have things neat, orderly and organized.

                 ______________________________________________________________________
                 6     To do new and different things often.

                 7     To have friends.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 6     To do new and different things often.
                 ______________________________________________________________________

                 2     To have influence with people.

                 5     To have as much freedom as possible to dot things I want to do.
                 ______________________________________________________________________

                 4     To do things for my family and others.

Attachment #8                                              174
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                 8     To create an atmosphere that makes for satisfying family living.
                 ______________________________________________________________________




                 Module 48 Handout: Values Clarification Survey

                 3     To have people think well of me.

                 7     To have friends.
                 ______________________________________________________________________

                 6     To do new and different things often.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

                 7     To have friends.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 2     To have influence with people.

                 7     To have friends.
                 ______________________________________________________________________

                 4     To do things for my family and others.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

                 5     To have as much freedom as possible to do things I want to do.

                 11    To have as many good things as possible.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 4     To do things for my family and others.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

Attachment #8                                              175
Solicitation No. 110068DC
                 7     To have friends.
                 ______________________________________________________________________

                 3     To have people think well of me.

                 12    To do things well.
                 ______________________________________________________________________




                 Module 48 Handout: Values Clarification Survey

                 1     To be reasonably sure about the future for my family and myself.

                 3     To have people think well of me.
                 ______________________________________________________________________

                 5     To have as much freedom as possible to do things I want to do.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 9     To do what is right according to my beliefs.
                 ______________________________________________________________________

                 7     To have friends.

                 12    To do things well.
                 ______________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 6     To do new and different things.
                 ______________________________________________________________________

                 2     To have influence over people.

                 6     To do new and different things.
                 ______________________________________________________________________

                 7     To have friends

                 9     To do right according to my beliefs
                 ______________________________________________________________________

                 3     To have people think well of me
Attachment #8                                              176
Solicitation No. 110068DC
                 10    To have things neat, orderly and organized
                 ______________________________________________________________________

                 2     To have influence over people

                 8     To create an atmosphere that makes for satisfying family living
                 _____________________________________________________________________




                 Module 48 Handout: Values Clarification Survey

                 1     To be reasonably sure about the future for my family and myself.

                 8     To create an atmosphere that makes for satisfying family living.
                 _____________________________________________________________________

                 2     To have influence over people

                 9     To do right according to my beliefs
                 _____________________________________________________________________

                 5     To have as much freedom as possible to do the things that I want to do.

                 10    To have things neat, orderly and organized.
                 _____________________________________________________________________

                 8     To create an atmosphere that makes for satisfying family living.

                 11    To have as many good things as possible.
                 _____________________________________________________________________

                 1     To be reasonably sure about the future for my family and myself.

                 11    To have as many good things as possible.
                 _____________________________________________________________________

                 2     To have influence with people

                 10    To have things neat, orderly and organized.
                 _____________________________________________________________________

                 3     To have people think well of me.

                 4     To do things for my family and others.
                 _____________________________________________________________________

Attachment #8                                              177
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                                       Module 48 Handout: Values Clarification Survey


                                                   FORCED VALUES TALLY SHEET



                                                                Number of times chosen
                                                    1   2   3   4 5 6 7 8 9 10           11   12
                                                                                                   Represents
                                           1                                                       SECURITY
        Number with chosen statement




                                           2                                                       INFLUENCE
                                           3                                                       RECOGNITION
                                           4                                                       HELPFULNESS
                                           5                                                       FREEDOM
                                           6                                                       NEW EXPERIENCE
                                           7                                                       FRIENDLINESS
                                           8                                                       FAMILY LIFE
                                           9                                                       MORAL STANDARDS
                                          10                                                       ORDERLINESS
                                          11                                                       WEALTH
                                          12                                                       WORKMANSHIP




Attachment #8                                                            178
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                 Module 48 Handout: Values Clarification Survey

                                 KEY TO FORCED CHOICE VALUES TEST
                 Directions:

                        1.      Look back on the test and count the number of times you circled each
                                number. You can use the Tally Sheet to help with this. Record the amount
                                to the left of each number on this key.
                        2.      Rank order those amounts to the right of the sentences corresponding
                                to the numbers. Rank the number with the greatest amount as
                                number 1.
                        3.      If a tie occurs, choose which quality is more important to you while
                                ranking.

                 No. of times
                 Circled                                     Rank        Key
                 __________1.                                __________ To be reasonably sure about
                 SECURITY                                                the future for my family and
                                                                         myself.

                 __________2.                                __________ To have influence with
                 INFLUENCE                                               people

                 __________3.                                __________ To have people think well of
                 RECOGNITION                                             me

                 __________4.                                __________ To do things for my family
                 HELPFULNESS                                            and others


                 __________5.                               __________ To have as much freedom as
                 FREEDOM                                                possible to do the things I
                                                                        want to do

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                 __________6.                   __________ To do new and different
                 NEW EXPERIENCE                             things often

                 __________7.                   __________ To have friends
                 FRIENDLINESS

                 __________8.                   __________ To arrange for a family
                 FAMILY LIFE                                atmosphere that makes for
                                                            satisfying family living




                 Module 48 Handout: Values Clarification Survey

                                 KEY TO FORCED CHOICE VALUES TEST

                 __________9.                   __________ To do what is right according
                 MORAL STANDARDS                            to my beliefs


                 __________10.                   __________ To have things neat, orderly
                 ORDERLINESS                                 and organized

                 __________11.                   __________ To have as many good things
                 WEALTH                                      as possible

                 __________12.                   __________ To do things well.
                 WORKMANSHIP




                 What are your top 3 values?

                 1.

                 2.

                 3.




Attachment #8                                   180
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                 Module 48 Handout: Values- Things or Concepts You Might Value


                 LIST OF VALUES

                 Acceptance         to fit in with others

                 Accuracy           to be correct in my opinions and actions

                 Achievement        to accomplish and achieve

                 Adventure          to have new and exciting experiences

                 Attractiveness     to be physically attractive

                 Authority          to be in charge of others

                 Beauty             to appreciate the beauty around me

                 Caring             to take care of others

                 Comfort            to have a pleasant enjoyable life

                 Compassion         to feel concern for others

                 Complexity         to have a life full of variety and change

                 Contribution       to make a contribution that will endure

                 Courtesy           to be polite and considerate of others

                 Creativity         to have new and original ideas
Attachment #8                                     181
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                 Dependability           to be reliable and trustworthy

                 Ecology                 to live in harmony with the environment

                 Faithfulness            to be loyal and reliable in relationships

                 Fame                    to be known and recognized

                 Family                  to have a happy, loving family

                 Flexibility             to adjust to a new or unusual situation easily

                 Forgiveness             to be forgiving of others

                 Friends                to have close, supportive friends




                 Module 48 Handout: Values- Things or Concepts You Might Value

                 Fun             to play and have fun

                 Generosity      to give what I have to others

                 God’s will      to seek and obey the will of God

                 Growth          to keep changing and growing

                 Health          to be physically fit and healthy

                 Helpfulness     to be helpful to others

                 Honesty         to be truthful and genuine

                 Hope            to maintain a positive and optimistic outlook

                 Humility        to be modest and unassuming

                 Humor           to se the humorous side of the world and myself

                 Independence    to be free from the dependence of others

                 Industry        to work hard and well at my life tasks

                 Inner Peace     to experience personal peace

                 Intimacy        to share my inner most feelings

                 Justice         to promote equal and fair treatment for all
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                 Knowledge        to learn and possess valuable knowledge

                 Leisure          to take time to relax and enjoy

                 Logic            to live rationally and sensibly

                 Loved            to be loved by those close to me

                 Loving           to give love to others

                 Moderation       to avoid excesses and find a middle ground

                 Monogamy         to have one close, loving relationship

                 Orderliness      to have a life that is well-ordered and organized




                 Module 48 Handout: Values- Things or Concepts You Might Value

                 Pleasure         to feel good

                 Popularity       to be well-liked by many people

                 Power            to have control over others

                 Responsibility   to make and carry out important decisions

                 Realism          to see and act realistically and practically

                 Risk             to take risks and chances

                 Romance          to have an intense, exciting love relationship

                 Safety           to be safe and secure

                 Self-control     to be disciplined and govern my own actions

                 Self-esteem      to like myself just as I am

                 Self-knowledge   to have a deep, honest understanding of myself

                 Service          to be of service to others

                 Sexuality        to have an active and satisfying sex life

                 Simplicity       to live life simply, with minimal needs

Attachment #8                                              183
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                 Stability      to have a life that stays consistent

                 Strength       to be physically strong

                 Spirituality   to grow spiritually

                 Tolerance      to respect and accept those different from me

                 Tradition      to follow the patterns of the past

                 Virtue         to live a morally pure and excellent life

                 Wealth         to have plenty of money

                 World Peace    to work to promote peace in the world




Attachment #8                                         184
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                                          Module 48 Main Points



      There are many different things/ concepts that you can value.

      What you value may not be what someone else values.

      You have certain “key values” that define who you are

      Your values dictate your choices.




Attachment #8                                        185
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Attachment #8               186
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                 Module 49 Handout: My Five Year Plan


                 Imagine how you want your life to be five years from now with regard to work, play,
                 relationships with others, and your relationship to yourself. Now think of the small goals that
                 you will need to achieve to make these goals come true. For example, if you see
                 yourself working as a computer specialist five years from now, your goals might be (1)
                 Earn my GED, (2) Attend technical school to learn basic computer skills, (3) take a entry
                 level position to gain computer programming experience, and (4) work for a top
                 computer software company.


                 A. Marriage and/or Family Goals: How would you like to develop or strengthen your
                 relationships. Include sharing of activities and the development of closeness.

                    Major Five Year Goal:__________________________________________

                    Subgoals:

                    1. __________________________              2._________________________

                    3. __________________________              4. _________________________

                    5. __________________________              6. _________________________

                    7. __________________________              8. _________________________


                 B. School and Work Goals: What are your school, work, and job objectives both short
                    term and long term?

                    Major Five Year Goal:____________________________________________

                    Subgoals:

                    1. __________________________              2._________________________

                    3. __________________________              4. _________________________

                    5. __________________________              6. _________________________

                    7. __________________________              8. _________________________




Attachment #8                                                187
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                 Module 49 Handout: My Five Year Plan



                 C. Social and Friendship Goals: What are your goals with regard to friends and social
                    activities? What groups or clubs or other organization do you want to be part of?

                    Major Five Year Goal:________________________________________________

                    Subgoals:

                    1. __________________________          2._________________________

                    3. __________________________          4. _________________________

                    5. __________________________          6. _________________________

                    7. __________________________          8. _________________________


                 D. Leisure Time and Recreation Goals: What do you want to do with your free time.
                    What hobbies, sports, or interests do you want to develop?

                    Major Five Year Goal:_______________________________________________

                    Subgoals:

                    1. __________________________          2._________________________

                    3. __________________________          4. _________________________

                    5. __________________________          6. _________________________

                    7. __________________________          8. _________________________


                 E. Personal Development Goals: What new attributes do you want to develop in
                    yourself? Strengthen? Decrease?

                    Major Five Year Goal:___________________________________________

                    Subgoals:

                    1. __________________________          2._________________________

                    3. __________________________          4. _________________________

                    5. __________________________          6. _________________________
Attachment #8                                            188
Solicitation No. 110068DC
                    7. __________________________    8. _________________________




Attachment #8                                       189
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                 Module 49 Handout: My Five Year Plan


                 F. Spiritual Goals: What would you like to see happen with your spiritual life?


                    Major Five Year Goal:__________________________________________

                    Subgoals:

                    1. __________________________            2._________________________

                    3. __________________________            4. _________________________

                    5. __________________________            6. _________________________

                    7. __________________________            8. _________________________


                 G. Emotional Goals: What emotions do you want to handle better? What feelings do
                    you want to feel more? Feel Less?

                    Major Five Year Goal:______________________________________________

                    Subgoals:

                    1. __________________________            2._________________________

                    3. __________________________            4. _________________________

                    5. __________________________            6. _________________________

                    7. __________________________            8. _________________________




Attachment #8                                              190
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                                          Module 49 Main Points



      It is not enough to have goals for the next few months.

      You should have goals for at least the next five years.

       Goals give our life direction.

      Goals give our lives meaning.

      Break down “BIG” goals into smaller sub-goals so that it does not feel overwhelming.

      Make your goals challenging but realistic and attainable.




Attachment #8                                          191
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                                         Module 50 Main Points



      Having a very strong and complete mental image of your future goals makes it more likely that you
      will achieve them.

      The future can be better than the past. It depends on your future choices.

      Starting and completing this group was a very good choice. Stay on the same path if you want a better
      future.




Attachment #8                                         192
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