Read Co-Occurring Disorders: text version

Transitional Services for High Risk Offenders with Co-Occurring Disorders

Co-Occurring Disorders:

When Mental Health and Substance Abuse Meet

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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 Attachment #8 1 Solicitation No. 110068DC

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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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 rarely 2 less than once a week 3 at least once a week 4 daily 5 more than once 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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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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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 CoOccurring 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 Risk Factors Close biological relative with a disorder Personality traits (high risk) Gender Ethnicity Protective Factors No family history of substance use or mental health problems Adaptive personality traits

Environmental Factors Risk Factors Life stressors Relationship issues Health & mental health Protective Factors Coping skills (reduce stress) Treating substance use & mental health problems

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

RELATIVE (E.G., PARENTS, SIBLINGS)

INCREASED CHANCE TO DEVELOP DISORDER 1.5 to 3 times more likely to develop Major Depressive Disorder 4 to 7 times more likely to develop Panic Disorder 4% to 24% more likely to develop Bipolar I Disorder

Major Depressive Disorder

Panic Disorder Bipolar I Disorder

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Bipolar I Disorder

4% to 24% more likely to develop Major Depressive Disorder 10 times more likely to develop Schizophrenia

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 anxietyprovoking 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 antidepressants 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 *Alcoholism / unmanageable life *Increased risk of liver disease, brain damage, car accidents, other diseases *Risk of death from alcohol poisoning *Decreased sex drive *Impotence *Depression *Sleep problems *Addiction / unmanageable life *Brain damage *Decreased motivation *Difficulty concentrating *Mood swings *Decreased sex drive *Impotence *Interferes with conception of children *Addiction / unmanageable life *Unmanageable life *Brain damage *Difficulty concentrating *Mood swings *Increased risk of fatal heart attack or stroke *Increased risk of lung disease, other diseases *Relaxation, sedation *Slowed reaction time *Impaired judgment *Loss of inhibition

Alcohol

Beer, wine, "hard liquor" (E.g., vodka, scotch, whiskey, gin, rum, tequila)

Cannabis

Marijuana, hashish

*Relaxation *Mild euphoria *Altered sensory experiences *Fatigue *Anxiety *Panic *Increased appetite *Paranoia

Stimulants

Cocaine Amphetamines (and related compounds)

*Increased alertness and energy *Decreased appetite *Positive feelings *Anxiety *Tension, feeling jittery, heart racing *Paranoia

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Effects of Different Psychoactive Substances

Substance Type Specific Substances Long Term Effects of Abuse Short Term Effects of Abuse *Addiction *Risk of death from overdose *Depression *Decreased motivation *Increased risk of HIV/AIDS, hepatitis, other diseases *Decreased sex drive *Impotence *Addiction / unmanageable life *Severe brain damage *Death, liver/ kidney failure *Sleepiness *Relaxation *Loss of motor coordination *Loss of inhibition *Dulled sensory experiences

Sedatives

Anxiolytic (anxiety lowering) medications (e.g., Xanax, Klonopin, Ativan, Valium) Barbituates

Inhalants

Glue Aerosols Nitrous oxide (laughing gas) Freon Antihistamines and related compounds (e.g., benadryl, other cold tablets)

*Altered perceptions *Disorientation

Over-the-counter medications

*Addiction *Sedation *Greatly increased risk of heart disease, lung diseases, all types of cancer, other diseases. *Increased risk of death *Decreased immune function *Decreased sex drive *Impotence *Alertness *Relaxation

Tobacco

Cigarettes Pipe tobacco Chewing tobacco Snuff Coffee Tea Chocolate Cogentin, Artane, Symmetrel

Caffeine

*Increased alertness

Anti-Parkinsonian Agents

*Confusion *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) 2) 3) 4) 5) Alcohol can cause depression in any individual Signs of temporary serious depression can occur in anyone after a period of prolonged drinking Drinking can escalate during a depressive episode Symptoms of depression and alcohol abuse occur in the context of other psychological disorders 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

1. A B (Bill feels hungry.) (He eats a piece of fresh-baked pie.) C+ (He feels much better.) A (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.) 3. A (A cat walks up to four-year-old Mark.) (He reaches out and B Csqueezes the cat too hard.) (The cat scratches Mark.) 4. A (Bob's wife comes home from work, walks into the kitchen and B says "Hello!" cheerfully. Bob who is in a bad mood), (snaps Cat 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 Csees Bob) (and says, "Hello!" cheerfully.) (Bob....snaps at her.) A B 5. (Six-year-old Billy feels lonely.) (He runs around the house

C+

2.

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. Attachment #8 Solicitation No. 110068DC 45

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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 my commitment Example: My family's support

Things that weaken my commitment Example: 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. 2. 3. 4. DENIAL: "I can quit anytime I want to" or "I'll just smoke marijuana but I won't do coke anymore." OVERCONFIDENCE: "It's all behind me now...there's no chance I'll ever do that again." 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. 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. IMPULSIVENESS: Acting without thinking, in many cases a reaction to stress. Impulsive acts can have far-reaching consequences LONELINESS: Isolation, avoiding other people, feeling alone. Solution - socialize, call a friend, go to an AA meeting, visit a relative. 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." 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. EXCESSIVE ANGER: Periods of anger, frustration and irritability. Is this an "excuse" to use drugs or drink?

5. 6. 7.

8. 9.

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: 1980).

Watching Out For "The Big Three" (Marlatt and Gordon,

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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Frank was sad about attending group today. (F) Janet gave Frank a hug. (B) Terry assumed that everyone would like the game. (T) Ruby pointed at the television. (B) Randy was happy when he earned a weekend pass. (F) John needed to visit his brother. (T) Jack was happy that his family was coming to visit this weekend. (F) Carl whispered to Joyce, "Don't worry." (B) Lucy realized that she shouldn't have yelled. (T) Rhonda is painting a picture. (B) Margaret's friends consider the movie to be good. (T) Joyce was fearful about meeting with the doctor. (F) Dorothy was angry when she had not earned an overnight pass. (F) The nurse pushed the medication cart towards the doctor's office. (B) Lucy expects to be able to help people. (T) Margaret yelled, "It's medication time." (B) Brian was amazed at how easily he could hit the target. (T) Patrick was fearful about his turn to play the game. (F) People often laugh at funny jokes. (B) Lisa was sad when she had not received a pay raise. (F)

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21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

Anna wished the dessert would be chocolate cake. (T) Harold and Betty believed that they should attend the group together. (T) Suzie smiled when told that she had won the prize. (B) Mona was fearful when her picture would not look as nice as Marsha's. (F) Marsha was angry when she ate lunch on the unit. (F) Walt drew a picture on the board. (B) Mona decided that her picture looked as nice as Marsha's. (T) Some people like to run for exercise. (B) Bonnie was happy when she got money in the letter from her mom. (F) Allison wondered whether she should go to the movie or not. (T) Johnny fantasized about flying a plane. (T) Karen was sad to say goodbye. (F) Marty is writing a thank you note to Connie. (B) Gary winked at me. (B) Sammy understood the assignment. (T) Judy was sad about the situation. (F) Arlene is angry about being broke. (F) A lot of people run for exercise. (B) Susan believed that he team would win first prize. (T) Jason is smoking a cigar. (B) Mona was happy when she finished her picture. (F) Jim wants to win the game. (T)

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43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64.

Mike expected to be in the Intermediate group. (T) William is sad that he is staying on the unit. (F) Ellen is sitting on the floor. (B) Tina's friends are happy that she can come home. (F) Carl and Tim are eating breakfast. (B) Burt considered himself a good team player. (T) Sally wants to be alone. (T) Martha grabbed the beanbag from Scott. (B) Sue was sad to have lost the game. (F) Sam was happy he won the game. (F) Larry is reading a sports magazine. (B) Allen hoped he could be the team captain. (T) Phyllis wants to have one more turn at the game. (T) Ron didn't get the prize and was angry. (F) Agnes is sleeping in the chair. (B) Bernie was fearful to ask for a cigarette. (F) Wendy was surprised when the fire alarm sounded. (T) Mark tossed the beanbag. (B) Ed decided that Martha was uncooperative. (T) Susan was happy she won the game. (F) Burt talked to Ed about the game. (B) Abe was sad Mark missed the target. (F) 81

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Abe thought Mark would hit the target. (T)

66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86.

Sally whispered, "I can't play this game." (B) Sally wanted to continue the game. (T) Sally pitched a beanbag and hit the target. (B) Charlie was sad when Sally won the game. (F) Mark was angry when he didn't get another turn. (F) Burt considered himself a good player. (T) Sally is smiling at Mark. (B) Mark kicked the beanbag across the floor. (B) Judy guessed that she would lose the game. (T) Judy is happy when she was able to play with the others. (F) Sally and Charlie were angry when they were told not to play the game. (F) Charlie believed that he and Sally should be able to play the game. (T) Tom laughed with Charlie. (B) Tony yelled at Wanda for missing the target. (B) Patrick wished he could go to the mall. (T) Martha loves to play cards. (F) Roxanne clapped her hands as the movie ended. (B) Arlene desires a new dress. (T) Mike was fearful about seeing the doctor. (F) Greg is sitting in the chair. (B) Ben imagined that Kevin would not go to lunch today. (T) 82

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Ben was angry when Kevin didn't show up for lunch. (F)

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88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110.

Hilary is juggling tennis balls. (B) Peggy decided to go on the picnic. (T) Vince was happy Peggy was at the picnic. (F) Connie was sad she didn't pass the test. (F) Connie cried after the group. (B) Connie believed she would pass the worksheet. (T) Stephanie considered the group difficult. (T) Margaret is waving good-bye. (B) Margaret is sad to be leaving her friends. (F) Becky is cooking hamburgers for lunch. (B) Jim expects Becky to have lunch with him today. (T) Jim is happy about Becky having lunch with him. (F) Harold is swimming in the pool. (B) John is sad he is sick. (F) Harold wanted John to feel better. (T) Diane is happy about Fran passing the test. (F) Jackie wished she would be able to go home this weekend. (T) Tom is walking to the store. (B) Jane guessed at the answer to the question. (T) Molly laughed at the cartoon. (B) Greg was angry when the party was over. (F) Larry tripped over the rug. (B) Lydia hoped to be elected president. (T) 84

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Lydia was happy to be elected secretary. (F) Alex is angry about not getting a raise in salary. (F) Alex expected a raise in his paycheck. (T) Alex ripped up the letter stating he didn't get a raise. (B) Paula has an idea about how to make money for the party. (T) Paula is washing cars to make money for the party. (B) Tom is happy since Paula is helping to earn money for the party. (F) Kelly is writing a poem, on a piece of paper. (B) Kelly is fearful that others won't like her poem. (F) Elaine thinks Kelly's poem is beautiful. (T) Sandy grabbed the last balloon. (B) Kim is angry she didn't get a card from her mother. (F) Kim expected a card from her mother. (T) Frank was sad he missed the concert. (F) Marsha is moving the T.V. (B) Frank believed he would go to the concert. (T) Jack is typing a letter. (B) Dick wants to be first in line. (T) Dick got angry when he wasn't first in line. (F) Eileen guessed the answer to the question. (T) Joe was crying about being late to group. (B) Diane was sad when she missed the bus. (F) 85

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Peter is painting a picture of a dog. (B) Alex is fearful of large dogs. (F) 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Frank was sad about attending group today. Janet gave Frank a hug. Terry assumed that everyone would like the game. Ruby pointed at the television. Randy was happy when he earned a weekend pass. John needed to visit his brother. Jack was happy that his family was coming to visit this weekend. Carl whispered to Joyce, "Don't worry." Lucy realized that she shouldn't have yelled. Rhonda is painting a picture. Margaret's friends consider the movie to be good. Joyce was fearful about meeting with the doctor. Dorothy was angry when she had not earned an overnight pass. The nurse pushed the medication cart towards the doctor's office. Lucy expects to be able to help people. Margaret yelled, "It's medication time." Brian was amazed at how easily he could hit the target. Patrick was fearful about his turn to play the game. People often laugh at funny jokes. Lisa was sad when she had not received a pay raise.

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Module 9 Handout: Thoughts,Feelings,Behavioro

21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

Anna wished the dessert would be chocolate cake. Harold and Betty believed that they should attend the group together. Suzie smiled when told that she had won the prize. Mona was fearful when her picture would not look as nice as Marsha's. Marsha was angry when she ate lunch on the unit. Walt drew a picture on the board. Mona decided that her picture looked as nice as Marsha's. Some people like to run for exercise. Bonnie was happy when she got money in the letter from her mom. Allison wondered whether she should go to the movie or not. Johnny fantasized about flying a plane. Karen was sad to say goodbye. Marty is writing a thank you note to Connie. Gary winked at me. Sammy understood the assignment. Judy was sad about the situation. Arlene is angry about being broke. A lot of people run for exercise. Susan believed that he team would win first prize. Jason is smoking a cigar. Mona was happy when she finished her picture. Jim wants to win the game.

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Module 9 Handout: Thoughts,Feelings,Behavioro

43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. Mike expected to be in the Intermediate group. William is sad that he is staying on the unit. Ellen is sitting on the floor. Tina's friends are happy that she can come home. Carl and Tim are eating breakfast. Burt considered himself a good team player. Sally wants to be alone. Martha grabbed the beanbag from Scott. Sue was sad to have lost the game. Sam was happy he won the game. Larry is reading a sports magazine. Allen hoped he could be the team captain. Phyllis wants to have one more turn at the game. Ron didn't get the prize and was angry. Agnes is sleeping in the chair. Bernie was fearful to ask for a cigarette. Wendy was surprised when the fire alarm sounded. Mark tossed the beanbag. Ed decided that Martha was uncooperative. Susan was happy she won the game. Burt talked to Ed about the game. Abe was sad Mark missed the target. Abe thought Mark would hit the target. 90

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Module 9 Handout: Thoughts,Feelings,Behavioro

66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. Sally whispered, "I can't play this game." Sally wanted to continue the game. Sally pitched a beanbag and hit the target. Charlie was sad when Sally won the game. Mark was angry when he didn't get another turn. Burt considered himself a good player. Sally is smiling at Mark. Mark kicked the beanbag across the floor. Judy guessed that she would lose the game. Judy is happy when she was able to play with the others. Sally and Charlie were angry when they were told not to play the game. Charlie believed that he and Sally should be able to play the game. Tom laughed with Charlie. Tony yelled at Wanda for missing the target. Patrick wished he could go to the mall. Martha loves to play cards. Roxanne clapped her hands as the movie ended. Arlene desires a new dress. Mike was fearful about seeing the doctor. Greg is sitting in the chair. Ben imagined that Kevin would not go to lunch today. Ben was angry when Kevin didn't show up for lunch.

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Module 9 Handout: Thoughts,Feelings,Behavioro

88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. Hilary is juggling tennis balls. Peggy decided to go on the picnic. Vince was happy Peggy was at the picnic. Connie was sad she didn't pass the test. Connie cried after the group. Connie believed she would pass the worksheet. Stephanie considered the group difficult. Margaret is waving good-bye. Margaret is sad to be leaving her friends. Becky is cooking hamburgers for lunch. Jim expects Becky to have lunch with him today. Jim is happy about Becky having lunch with him. Harold is swimming in the pool. John is sad he is sick. Harold wanted John to feel better. Diane is happy about Fran passing the test. Jackie wished she would be able to go home this weekend. Tom is walking to the store. Jane guessed at the answer to the question. Molly laughed at the cartoon. Greg was angry when the party was over. Larry tripped over the rug. Lydia hoped to be elected president. 93

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Module 9 Handout: Thoughts,Feelings,Behavioro

111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. Lydia was happy to be elected secretary. Alex is angry about not getting a raise in salary. Alex expected a raise in his paycheck. Alex ripped up the letter stating he didn't get a raise. Paula has an idea about how to make money for the party. Paula is washing cars to make money for the party. Tom is happy since Paula is helping to earn money for the party. Kelly is writing a poem, on a piece of paper. Kelly is fearful that others won't like her poem. Elaine thinks Kelly's poem is beautiful. Sandy grabbed the last balloon. Kim is angry she didn't get a card from her mother. Kim expected a card from her mother. Frank was sad he missed the concert. Marsha is moving the T.V. Frank believed he would go to the concert. Jack is typing a letter. Dick wants to be first in line. Dick got angry when he wasn't first in line. Eileen guessed the answer to the question. Joe was crying about being late to group. Diane was sad when she missed the bus.

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Module 9 Handout: Thoughts,Feelings,Behavioro

133. 134. 135. Peter is painting a picture of a dog. Alex is fearful of large dogs. 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: trigger a relapse? What are some feelings that might

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 (longrange 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, feelings and negative thoughts. "Thinking or Feeling Report" of their sad

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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.

alcohol could have on someone who was trying to use them to combat an anxiety disorder?

Question 6: What are some specific negative effects that drugs

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 anxietyrelated 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 Name

Generic Name

Benzodiazepines Ativan Lorazepam Compazine Prochlorperazine Klonopin Clonazepam Librium Chlordiazepoxide Valium Diazepam Xanax Alprazolam Non Buspar Buspirone Benzodiazepine *Atarax (Vistaril) Hydroxyzine hydrochloride

Average Dosage Range (mg/day) 2-10 15-150 0.5-16 5-100 2-40 0.75-4 15-60

Possible Side Effects Drowsiness, loss of coordination, fatigue, mental slowing, and confusion

All benzodiazepines have the potential for addiction Dizziness, nausea, headache, fatigue, nervousness, lightheadedness, and excitement 200-400 Sleepiness, dizziness, and 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 longlasting 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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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 3: People often feel great while they are manic (e.g., euphoric mood,

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 shortlived 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?

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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.

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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 Name Chemical Name Average Dosage Range (mg/day)

900-3600

Possible Side Effects

Lithium

Eskalith Eskalith Controlled Release

lithium carbonate

Tremors, dry mouth, muscle weakness, fluid buildup, diarrhea, nausea, vomiting, mental confusion, lack of coordination, drowsiness Nausea, vomiting, indigestion, tremors, drowsiness, weight gain, elevated liver enzymes Skin rashes, sensitivity to the sun, headaches, dizziness, nausea, weakness, tiredness, blurred or double vision

Anticonvulsants

Tegretol Depakene, Depakote Lamictal

carbamazepine valproic acid lamotrigine

100-2000 125-2000 25-500

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. That is, how might a person with it think, feel, and act?

Question 1: What are the signs and symptoms of schizophrenia?

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?

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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 shortterm; 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.

taking antipsychotic medications over self-medicating with drugs?

Question 11: What are the benefits and drawbacks of

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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 Name Clozaril** Haldol*** Loxitane Mellaril Moban Navane Chemical Name Clozapine Haloperidol Loxapine Thioridazine Molindone Thiothixene Average Dosage Range (mg/day)* 200-900 1-40 4-250 50-600 15-250 6-60 1-40 1-8 25-300 150-750 4-60 50-1250 8-64 5-20 Possible Side Effects

Dry mouth, drowsiness, blurred vision, constipation, urinary retention, nose bleeds, dizziness

Prolixin*** Fluphenazine Risperdal** Risperidone Serentil Seroquel Stelazine Thorazine Trilafon Zyprexa * Mesoridazine Quetiapine Trifluoperazine Chlorpromazine Perphenazine Olanzapine

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 Name Artane Benadryl Cogentin Kemadrin Dopamine agonist Benzodiazepines Chemical Name Average Dosage Range (mg/day) Trihexyphenidyl 5-15 Diphenhydramin Benztropine Procyclidine 50-300 0.5-8 5-20 100-400 Increase in "present" symptoms 2-10 15-150 0.5-16 5-100 2-40 0.75-4 Drowsiness, psychomotor impairment, memory loss, psychological and physiological dependence, Possible Side Effects

Anticholinergic

Dry mouth, constipation, blurry vision, drowsiness, urinary retention, memory loss

Symmetrel Amatadine Ativan Lorazepam

Compazine Prochlorperazine Klonopin Librium Valium Xanax Clonazepam Chlordiazepoxide Diazepam Alprazolam

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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". 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". 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". 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". 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." 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".

2.

3.

4.

5.

6.

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." 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."

8.

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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. 2. 3. 4. 5. 6. 7. 8. 9. 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. There should be an EASY, MAGICAL WAY to change! If I understand how I got this way, I'll easily and magically change, with no effort on my part. My therapist should change me! I've been this way TOO LONG to change! I can only change by venting my feelings (screaming, yelling, blaming others/moaning and whining), and this will magically change things. Therapy is too boring. It should be more interesting. Therapy is too rigorous if it requires me to DO SOMETHING. 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 selfawareness. 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 jokeHow 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.

+ of solution

Solution #1 - of solution

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Module 21 Handout: Healthy Decisions

+ of solution

Solution #2 - of solution

+ of solution

Solution #3 - 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. 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.

2.

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. Using other drugs will likely set you up to become addicted to other substances. You should be prepared for comments like: Using prescription drugs is "just another kind of dependence."

4. 5.

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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

What caused my urge?

Thoughts/ Feelings

What was I thinking & feeling?

Behavior

What did I do then?

+ Consequences

What positive things happened?

- Consequences

What negative things 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 o o Exposure to alcohol or drugs themselves. Seeing other people using. 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. surprise and there is a safe/ easy way to leave the situation.

E- Escape from what is triggering you. This is a good option when a trigger catches you by

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 nonjudgmental 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 selftalk 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) 2) 3) 4) 5) This is going to tempt me, but I know how to deal with it. Remember to list all of my coping tactics. The urges will come but I'll be okay, I know how to cope. Relax-take a deep breath. Easy does it. Remember to keep my sense of humor.

Coping When Cravings Start to Build Self-talk strategies (Script #2): 1) 2) 3) 4) 5) 6) It's time to relax and slow down. My craving is a signal of what I need to do. Breathe... If I feel it, I can do some "urge surfing." Watch out now for some "stinking thinking." One will lead to another so I can't let myself do it. 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) 2) 3) 4) 5) 6) As long as I keep my cool and use my coping skills, I'm in control. Think of what I want to get out of this. What is my long-term goal. I don't need to prove myself or test my will power. Remember that this urge will pass quickly, if I do nothing. Remember to breathe and relax. Do the urge surfing now. If it doesn't work, I can leave the situation. 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 5/16/98 Situation (include your thoughts &feelings) Intensity of Cravings (1-100) Coping Behaviors Used

Was feeling stressed and worried. Had bad phone call home.

75

Took a shower. Listened to 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.

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.

OBJECTIVES: 1. To review the relapse prevention model and give an overview of this module.

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 fullblown 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 Attachment #8 Solicitation No. 110068DC 256

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

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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OBJECTIVES: 1. To review the importance of lifestyle balance in relapse prevention. 2. To help

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, selfdestructive 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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Lifestyle Dimension

Priority 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, selfgrowth, 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

Lifestyle Dimension

Priority 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, selfgrowth, 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 selfharm, 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. Attachment #8 Solicitation No. 110068DC 269

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)

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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 Attachment #8 285 Solicitation No. 110068DC

"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 thought about visiting his old friend. Joe manages to not buy drugs from the dealers and buys toothpaste. Joe enters the apartment where a drug party is going on. Joe feels good for a moment. Then he feels really bad about using and wants more of the drug to try to feel better. Joe "crashes" and feels terrible.

1.Joe missed his counseling session during the week. 2. Joe rationalizes his visit to the old neighborhood by telling himself that he needs to get toothpaste there. 3. Joe feels overconfident about not buying from the dealers. 4. Joe gets offered drugs and feels that he now has it under control and can stop after just one. 5. Joe feels bad about using. 6. The drugs and money run out and friends invite him to help them get more money for drugs.

Joe did not plan his weekend

Joe walks through the old neighborhood. He decides to knock on his old friend's door to brag about how ell he is doing in recovery.

Joe takes one hit. Joe takes more drugs. Joe goes with his friends and ends up ribbing a convenience store.

Joe is arrested and sent to 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."

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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 If a lot of time remains, have members of the group the session. 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 "highrisk 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. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________

B. School and Work Goals: What are your school, work, and job objectives, both short-term and long-term? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 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. ______________________________ 3. ______________________________ 5. ______________________________ Attachment #8 Solicitation No. 110068DC 311 2. _____________________________ 4. _____________________________ 6. _____________________________

7. ______________________________

8. _____________________________

Module 37 Handout: Life Goals

D. Leisure Time and Recreation Goals: What do you want to do with your free time? hobbies, sports, or interests do you want to develop? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________ What

E. Personal Development Goals: What new attributes do you want to develop in yourself? Strengthen? Decrease? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________

F. Spiritual Goals: What would you like to see happen with your spiritual life? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________

G. Emotional Goals: What emotions do you want to handle better? What feelings do you want to feel more? Feel less? 1. ______________________________ Attachment #8 Solicitation No. 110068DC 312 2. _____________________________

3. ______________________________ 5. ______________________________ 7. ______________________________

4. _____________________________ 6. _____________________________ 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-topAttachment #8 Solicitation No. 110068DC 316

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. number 1. Write it down under

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 highrisk 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 _____. reward yourself? How did you

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. under number 1. Write it down

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 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 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 ______. reward yourself? How did you

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 nontrigger 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 Attachment #8 Solicitation No. 110068DC 349

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?

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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, selfefficacy 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' selfimage.

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 What are the benefits/payoffs of using drugs and alcohol? What do you gain by using?

Advantages/Benefits What are the benefits/ payoffs of being clean and sober? What do you gain by not using?

Disadvantages/ Losses What are the negatives/downside of using drugs and alcohol? What do you lose by using?

Disadvantages/ Losses What are the negatives/ downside of staying clean and sober? What do you lose by not using?

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Module 47 Handout: Payoff Matrix Substance Abuse

The Behavior: Using drugs and alcohol.

Advantages/Benefits 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Advantages/Benefits

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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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Advantages/Benefits 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Advantages/Benefits 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 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 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.

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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. 372

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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. ______________________________________________________________________ Attachment #8 Solicitation No. 110068DC 373

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 Solicitation No. 110068DC 374

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 10 To do what is right according to my beliefs. 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. 375

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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. 376

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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 377

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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 Solicitation No. 110068DC 378

Module 48 Handout: Values Clarification Survey

FORCED VALUES TALLY SHEET

1 1 2 3 4 5 6 7 8 9 10 11 12 Number with chosen statement

2

3

Number of times chosen 4 5 6 7 8 9 10

11

12 Represents SECURITY INFLUENCE RECOGNITION HELPFULNESS FREEDOM NEW EXPERIENCE FRIENDLINESS FAMILY LIFE MORAL STANDARDS ORDERLINESS WEALTH WORKMANSHIP

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Module 48 Handout: Values Clarification Survey

KEY TO FORCED CHOICE VALUES TEST

Directions: 1. 2. 3. No. of times Circled __________1. SECURITY __________2. INFLUENCE __________3. RECOGNITION __________4. HELPFULNESS __________5. FREEDOM Attachment #8 Solicitation No. 110068DC 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. Rank order those amounts to the right of the sentences corresponding to the numbers. Rank the number with the greatest amount as number 1. If a tie occurs, choose which quality is more important to you while ranking. Rank Key __________ To be reasonably sure about the future for my family and myself. __________ To have influence with people __________ To have people think well of me __________ To do things for my family and others __________ To have as much freedom as possible to do the things I want to do 380

__________6. NEW EXPERIENCE __________7. FRIENDLINESS __________8. FAMILY LIFE

__________ To do new and different things often __________ To have friends __________ To arrange for a family atmosphere that makes for satisfying family living

Module 48 Handout: Values Clarification Survey

KEY TO FORCED CHOICE VALUES TEST

__________9. MORAL STANDARDS __________10. ORDERLINESS __________11. WEALTH __________12. WORKMANSHIP __________ To do what is right according to my beliefs __________ To have things neat, orderly and organized __________ To have as many good things as possible __________ To do things well.

What are your top 3 values? 1. 2. 3.

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Module 48 Handout: Values- Things or Concepts You Might Value

LIST OF VALUES

Acceptance Accuracy Achievement Adventure Attractiveness Authority Beauty Caring Comfort Compassion Complexity Contribution Courtesy Attachment #8 Solicitation No. 110068DC to fit in with others to be correct in my opinions and actions to accomplish and achieve to have new and exciting experiences to be physically attractive to be in charge of others to appreciate the beauty around me to take care of others to have a pleasant enjoyable life to feel concern for others to have a life full of variety and change to make a contribution that will endure to be polite and considerate of others 382

Creativity Dependability Ecology Faithfulness Fame Family Flexibility Forgiveness Friends

to have new and original ideas to be reliable and trustworthy to live in harmony with the environment to be loyal and reliable in relationships to be known and recognized to have a happy, loving family to adjust to a new or unusual situation easily to be forgiving of others to have close, supportive friends

Module 48 Handout: Values- Things or Concepts You Might Value

Fun Generosity God's will Growth Health Helpfulness Honesty Hope Humility Humor Independence Industry Inner Peace Intimacy Attachment #8 Solicitation No. 110068DC to play and have fun to give what I have to others to seek and obey the will of God to keep changing and growing to be physically fit and healthy to be helpful to others to be truthful and genuine to maintain a positive and optimistic outlook to be modest and unassuming to se the humorous side of the world and myself to be free from the dependence of others to work hard and well at my life tasks to experience personal peace to share my inner most feelings 383

Justice Knowledge Leisure Logic Loved Loving Moderation Monogamy Orderliness

to promote equal and fair treatment for all to learn and possess valuable knowledge to take time to relax and enjoy to live rationally and sensibly to be loved by those close to me to give love to others to avoid excesses and find a middle ground to have one close, loving relationship to have a life that is well-ordered and organized

Module 48 Handout: Values- Things or Concepts You Might Value

Pleasure Popularity Power Responsibility Realism Risk Romance Safety Self-control Self-esteem Self-knowledge Service Sexuality Simplicity Attachment #8 Solicitation No. 110068DC to feel good to be well-liked by many people to have control over others to make and carry out important decisions to see and act realistically and practically to take risks and chances to have an intense, exciting love relationship to be safe and secure to be disciplined and govern my own actions to like myself just as I am to have a deep, honest understanding of myself to be of service to others to have an active and satisfying sex life to live life simply, with minimal needs 384

Stability Strength Spirituality Tolerance Tradition Virtue Wealth World Peace

to have a life that stays consistent to be physically strong to grow spiritually to respect and accept those different from me to follow the patterns of the past to live a morally pure and excellent life to have plenty of money to work to promote peace in the world

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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.

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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.

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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."

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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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ Attachment #8 Solicitation No. 110068DC 2._________________________ 4. _________________________ 6. _________________________ 8. _________________________ 389

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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 8. _________________________

E. Personal Development Goals: What new attributes do you want to develop in yourself? Strengthen? Decrease? Major Five Year Goal:___________________________________________ Subgoals: Attachment #8 Solicitation No. 110068DC 390

1. __________________________ 3. __________________________ 5. __________________________ 7. __________________________

2._________________________ 4. _________________________ 6. _________________________ 8. _________________________

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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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 8. _________________________

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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.

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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 Risk Factors Close biological relative with a disorder Personality traits (high risk) Gender Ethnicity Protective Factors No family history of substance use or mental health problems Adaptive personality traits

Environmental Factors Risk Factors Life stressors Relationship issues Health & mental health Protective Factors Coping skills (reduce stress) Treating substance use & mental health problems

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 *Alcoholism / unmanageable life *Increased risk of liver disease, brain damage, car accidents, other diseases *Risk of death from alcohol poisoning *Decreased sex drive *Impotence *Depression *Sleep problems *Relaxation, sedation *Slowed reaction time *Impaired judgment *Loss of inhibition

Alcohol

Beer, wine, "hard liquor" (E.g., vodka, scotch, whiskey, gin, rum, tequila)

Cannabis

Marijuana, hashish

*Addiction / unmanageable life *Brain damage *Decreased motivation *Difficulty concentrating *Mood swings *Decreased sex drive *Impotence *Interferes with conception of children

*Relaxation *Mild euphoria *Altered sensory experiences *Fatigue *Anxiety *Panic *Increased appetite *Paranoia

Stimulants

Cocaine Amphetamines (and related compounds)

*Addiction / unmanageable life *Unmanageable life *Brain damage *Difficulty concentrating *Mood swings *Increased risk of fatal heart attack or stroke *Increased risk of lung disease, other diseases

*Increased alertness and energy *Decreased appetite *Positive feelings *Anxiety *Tension, feeling jittery, heart racing *Paranoia

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Effects of Different Psychoactive Substances

Substance Type Specific Substances Long Term Effects of Abuse Short Term Effects of Abuse *Addiction *Risk of death from overdose *Depression *Decreased motivation *Increased risk of HIV/AIDS, hepatitis, other diseases *Decreased sex drive *Impotence *Sleepiness *Relaxation *Loss of motor coordination *Loss of inhibition *Dulled sensory experiences

Sedatives

Anxiolytic (anxiety lowering) medications (e.g., Xanax, Klonopin, Ativan, Valium) Barbituates

Inhalants

Glue Aerosols Nitrous oxide (laughing gas) Freon

*Addiction / unmanageable life *Severe brain damage *Death, liver/ kidney failure

*Altered perceptions *Disorientation

Over-the-counter medications

Antihistamines and related compounds (e.g., benadryl, other cold tablets)

*Addiction *Sedation *Greatly increased risk of heart disease, lung diseases, all types of cancer, other diseases. *Increased risk of death *Decreased immune function *Decreased sex drive *Impotence

Tobacco

Cigarettes Pipe tobacco Chewing tobacco Snuff

*Alertness *Relaxation

Caffeine

Coffee Tea Chocolate Cogentin, Artane, Symmetrel

*Increased alertness

Anti-Parkinsonian Agents

*Confusion *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 my commitment Example: My family's support

Things that weaken my commitment Example: 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." OVERCONFIDENCE: "It's all behind me now...there's no chance I'll ever do that again." 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. 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. IMPULSIVENESS: Acting without thinking, in many cases a reaction to stress. Impulsive acts can have far-reaching consequences LONELINESS: Isolation, avoiding other people, feeling alone. Solution - socialize, call a friend, go to an AA meeting, visit a relative. 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." 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. EXCESSIVE ANGER: Periods of anger, frustration and irritability. Is this an "excuse" to use drugs or drink?

2. 3.

4.

5.

6.

7.

8.

9.

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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Frank was sad about attending group today. Janet gave Frank a hug. Terry assumed that everyone would like the game. Ruby pointed at the television. Randy was happy when he earned a weekend pass. John needed to visit his brother. Jack was happy that his family was coming to visit this weekend. Carl whispered to Joyce, "Don't worry." Lucy realized that she shouldn't have yelled. Rhonda is painting a picture. Margaret's friends consider the movie to be good. Joyce was fearful about meeting with the doctor. Dorothy was angry when she had not earned an overnight pass. The nurse pushed the medication cart towards the doctor's office. Lucy expects to be able to help people. Margaret yelled, "It's medication time." Brian was amazed at how easily he could hit the target. Patrick was fearful about his turn to play the game. People often laugh at funny jokes. Lisa was sad when she had not received a pay raise.

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Module 9 Handout: Thoughts,Feelings,Behavioro

21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

Anna wished the dessert would be chocolate cake. Harold and Betty believed that they should attend the group together. Suzie smiled when told that she had won the prize. Mona was fearful when her picture would not look as nice as Marsha's. Marsha was angry when she ate lunch on the unit. Walt drew a picture on the board. Mona decided that her picture looked as nice as Marsha's. Some people like to run for exercise. Bonnie was happy when she got money in the letter from her mom. Allison wondered whether she should go to the movie or not. Johnny fantasized about flying a plane. Karen was sad to say goodbye. Marty is writing a thank you note to Connie. Gary winked at me. Sammy understood the assignment. Judy was sad about the situation. Arlene is angry about being broke. A lot of people run for exercise. Susan believed that he team would win first prize. Jason is smoking a cigar. Mona was happy when she finished her picture. Jim wants to win the game.

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Module 9 Handout: Thoughts,Feelings,Behavioro

43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. Mike expected to be in the Intermediate group. William is sad that he is staying on the unit. Ellen is sitting on the floor. Tina's friends are happy that she can come home. Carl and Tim are eating breakfast. Burt considered himself a good team player. Sally wants to be alone. Martha grabbed the beanbag from Scott. Sue was sad to have lost the game. Sam was happy he won the game. Larry is reading a sports magazine. Allen hoped he could be the team captain. Phyllis wants to have one more turn at the game. Ron didn't get the prize and was angry. Agnes is sleeping in the chair. Bernie was fearful to ask for a cigarette. Wendy was surprised when the fire alarm sounded. Mark tossed the beanbag. Ed decided that Martha was uncooperative. Susan was happy she won the game. Burt talked to Ed about the game. Abe was sad Mark missed the target. Abe thought Mark would hit the target. 36

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Module 9 Handout: Thoughts,Feelings,Behavioro

66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. Sally whispered, "I can't play this game." Sally wanted to continue the game. Sally pitched a beanbag and hit the target. Charlie was sad when Sally won the game. Mark was angry when he didn't get another turn. Burt considered himself a good player. Sally is smiling at Mark. Mark kicked the beanbag across the floor. Judy guessed that she would lose the game. Judy is happy when she was able to play with the others. Sally and Charlie were angry when they were told not to play the game. Charlie believed that he and Sally should be able to play the game. Tom laughed with Charlie. Tony yelled at Wanda for missing the target. Patrick wished he could go to the mall. Martha loves to play cards. Roxanne clapped her hands as the movie ended. Arlene desires a new dress. Mike was fearful about seeing the doctor. Greg is sitting in the chair. Ben imagined that Kevin would not go to lunch today. Ben was angry when Kevin didn't show up for lunch.

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Module 9 Handout: Thoughts,Feelings,Behavioro

88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. Hilary is juggling tennis balls. Peggy decided to go on the picnic. Vince was happy Peggy was at the picnic. Connie was sad she didn't pass the test. Connie cried after the group. Connie believed she would pass the worksheet. Stephanie considered the group difficult. Margaret is waving good-bye. Margaret is sad to be leaving her friends. Becky is cooking hamburgers for lunch. Jim expects Becky to have lunch with him today. Jim is happy about Becky having lunch with him. Harold is swimming in the pool. John is sad he is sick. Harold wanted John to feel better. Diane is happy about Fran passing the test. Jackie wished she would be able to go home this weekend. Tom is walking to the store. Jane guessed at the answer to the question. Molly laughed at the cartoon. Greg was angry when the party was over. Larry tripped over the rug. Lydia hoped to be elected president. 39

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Module 9 Handout: Thoughts,Feelings,Behavioro

111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. Lydia was happy to be elected secretary. Alex is angry about not getting a raise in salary. Alex expected a raise in his paycheck. Alex ripped up the letter stating he didn't get a raise. Paula has an idea about how to make money for the party. Paula is washing cars to make money for the party. Tom is happy since Paula is helping to earn money for the party. Kelly is writing a poem, on a piece of paper. Kelly is fearful that others won't like her poem. Elaine thinks Kelly's poem is beautiful. Sandy grabbed the last balloon. Kim is angry she didn't get a card from her mother. Kim expected a card from her mother. Frank was sad he missed the concert. Marsha is moving the T.V. Frank believed he would go to the concert. Jack is typing a letter. Dick wants to be first in line. Dick got angry when he wasn't first in line. Eileen guessed the answer to the question. Joe was crying about being late to group. Diane was sad when she missed the bus.

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Module 9 Handout: Thoughts,Feelings,Behavioro

133. 134. 135. Peter is painting a picture of a dog. Alex is fearful of large dogs. 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?

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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.

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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". 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". 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". 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". 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." 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".

2.

3.

4.

5.

6.

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." 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."

8.

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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. There should be an EASY, MAGICAL WAY to change! If I understand how I got this way, I'll easily and magically change, with no effort on my part. My therapist should change me! I've been this way TOO LONG to change! I can only change by venting my feelings (screaming, yelling, blaming others/moaning and whining), and this will magically change things. Therapy is too boring. It should be more interesting. Therapy is too rigorous if it requires me to DO SOMETHING. I'll only change if my therapist and the rest of the world loves me, otherwise, it's TOO HARD.

2. 3.

4. 5. 6.

7. 8. 9.

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 jokeHow 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.

+ of solution

Solution #1 - of solution

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Module 21 Handout: Healthy Decisions

+ of solution

Solution #2 - of solution

+ of solution

Solution #3 - 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

What caused my urge?

Thoughts/ Feelings

What was I thinking & feeling?

Behavior

What did I do then?

+ Consequences

What positive things happened?

- Consequences

What negative things 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 o o Exposure to alcohol or drugs themselves. Seeing other people using. 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) 2) 3) 4) 5) This is going to tempt me, but I know how to deal with it. Remember to list all of my coping tactics. The urges will come but I'll be okay, I know how to cope. Relax-take a deep breath. Easy does it. Remember to keep my sense of humor.

Coping When Cravings Start to Build

Self-talk strategies (Script #2): 1) 2) 3) 4) 5) 6) It's time to relax and slow down. My craving is a signal of what I need to do. Breathe... If I feel it, I can do some "urge surfing." Watch out now for some "stinking thinking." One will lead to another so I can't let myself do it. 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) 2) 3) 4) As long as I keep my cool and use my coping skills, I'm in control. Think of what I want to get out of this. What is my long-term goal. I don't need to prove myself or test my will power. Remember that this urge will pass quickly, if I do nothing. Remember to breathe and relax. Do the urge surfing now. If it doesn't work, I can leave the situation. Look for the positive. Don't assume the worst or jump to conclusions.

5) 6)

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 5/16/98 Situation (include your thoughts &feelings) Intensity of Cravings (1-100) Coping Behaviors Used

Was feeling stressed and worried. Had bad phone call home.

75

Took a shower. Listened to 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, selfdestructive 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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Lifestyle Dimension

Priority 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, selfgrowth, reading, etc.

Other

Module 30 Handout: Dimensions of Lifestyle Balance for Recovery

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Lifestyle Dimension

Priority 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, selfgrowth, 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. Attachment #8 Solicitation No. 110068DC 114

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 thought about visiting his old friend. Joe manages to not buy drugs from the dealers and buys toothpaste. Joe enters the apartment where a drug party is going on. Joe feels good for a moment. Then he feels really bad about using and wants more of the drug to try to feel better. Joe "crashes" and feels terrible.

1.Joe missed his counseling session during the week. 2. Joe rationalizes his visit to the old neighborhood by telling himself that he needs to get toothpaste there. 3. Joe feels overconfident about not buying from the dealers. 4. Joe gets offered drugs and feels that he now has it under control and can stop after just one. 5. Joe feels bad about using. 6. The drugs and money run out and friends invite him to help them get more money for drugs.

Joe did not plan his weekend

Joe walks through the old neighborhood. He decides to knock on his old friend's door to brag about how ell he is doing in recovery.

Joe takes one hit. Joe takes more drugs. Joe goes with his friends and ends up ribbing a convenience store.

Joe is arrested and sent to 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. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________

B. School and Work Goals: What are your school, work, and job objectives, both short-term and long-term? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 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. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 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? hobbies, sports, or interests do you want to develop? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________

What

E. Personal Development Goals: What new attributes do you want to develop in yourself? Strengthen? Decrease? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________

F. Spiritual Goals: What would you like to see happen with your spiritual life? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________

G. Emotional Goals: What emotions do you want to handle better? What feelings do you want to feel more? Feel less? 1. ______________________________ 3. ______________________________ 5. ______________________________ 7. ______________________________ Attachment #8 Solicitation No. 110068DC 129 2. _____________________________ 4. _____________________________ 6. _____________________________ 8. _____________________________

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 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 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

3.

4.

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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 nontrigger 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 _________________ Attachment #8 Solicitation No. 110068DC 153

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? Attachment #8 Solicitation No. 110068DC 159

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 What are the benefits/payoffs of using drugs and alcohol? What do you gain by using?

Advantages/Benefits What are the benefits/ payoffs of being clean and sober? What do you gain by not using?

Disadvantages/ Losses What are the negatives/downside of using drugs and alcohol? What do you lose by using?

Disadvantages/ Losses What are the negatives/ downside of staying clean and sober? What do you lose by not using?

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Module 47 Handout: Payoff Matrix Substance Abuse

The Behavior: Using drugs and alcohol.

Advantages/Benefits 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Advantages/Benefits

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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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Advantages/Benefits 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Advantages/Benefits 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Disadvantages/ Losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 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. 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. ______________________________________________________________________ Attachment #8 Solicitation No. 110068DC 172

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 Solicitation No. 110068DC 173

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 10 To do what is right according to my beliefs. 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. 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. 175

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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 176

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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 Solicitation No. 110068DC 177

Module 48 Handout: Values Clarification Survey

FORCED VALUES TALLY SHEET

1 1 2 3 4 5 6 7 8 9 10 11 12 Number with chosen statement

2

3

Number of times chosen 4 5 6 7 8 9 10

11

12 Represents SECURITY INFLUENCE RECOGNITION HELPFULNESS FREEDOM NEW EXPERIENCE FRIENDLINESS FAMILY LIFE MORAL STANDARDS ORDERLINESS WEALTH WORKMANSHIP

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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. Rank order those amounts to the right of the sentences corresponding to the numbers. Rank the number with the greatest amount as number 1. If a tie occurs, choose which quality is more important to you while ranking.

2.

3.

No. of times Circled __________1. SECURITY

Rank Key __________ To be reasonably sure about the future for my family and myself. __________ To have influence with people __________ To have people think well of me __________ To do things for my family and others

__________2. INFLUENCE __________3. RECOGNITION __________4. HELPFULNESS

__________5. FREEDOM

__________ To have as much freedom as possible to do the things I want to do 179

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__________6. NEW EXPERIENCE __________7. FRIENDLINESS __________8. FAMILY LIFE

__________ To do new and different things often __________ To have friends

__________ To arrange for a family atmosphere that makes for satisfying family living

Module 48 Handout: Values Clarification Survey

KEY TO FORCED CHOICE VALUES TEST

__________9. MORAL STANDARDS __________ To do what is right according to my beliefs

__________10. ORDERLINESS __________11. WEALTH __________12. WORKMANSHIP

__________ To have things neat, orderly and organized __________ To have as many good things as possible __________ To do things well.

What are your top 3 values? 1. 2. 3.

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Module 48 Handout: Values- Things or Concepts You Might Value

LIST OF VALUES

Acceptance Accuracy Achievement Adventure Attractiveness Authority Beauty Caring Comfort Compassion Complexity Contribution Courtesy Creativity Attachment #8 Solicitation No. 110068DC to fit in with others to be correct in my opinions and actions to accomplish and achieve to have new and exciting experiences to be physically attractive to be in charge of others to appreciate the beauty around me to take care of others to have a pleasant enjoyable life to feel concern for others to have a life full of variety and change to make a contribution that will endure to be polite and considerate of others to have new and original ideas 181

Dependability Ecology Faithfulness Fame Family Flexibility Forgiveness Friends

to be reliable and trustworthy to live in harmony with the environment to be loyal and reliable in relationships to be known and recognized to have a happy, loving family to adjust to a new or unusual situation easily to be forgiving of others to have close, supportive friends

Module 48 Handout: Values- Things or Concepts You Might Value

Fun Generosity God's will Growth Health Helpfulness Honesty Hope Humility Humor Independence Industry Inner Peace Intimacy Justice Attachment #8 Solicitation No. 110068DC to play and have fun to give what I have to others to seek and obey the will of God to keep changing and growing to be physically fit and healthy to be helpful to others to be truthful and genuine to maintain a positive and optimistic outlook to be modest and unassuming to se the humorous side of the world and myself to be free from the dependence of others to work hard and well at my life tasks to experience personal peace to share my inner most feelings to promote equal and fair treatment for all 182

Knowledge Leisure Logic Loved Loving Moderation Monogamy Orderliness

to learn and possess valuable knowledge to take time to relax and enjoy to live rationally and sensibly to be loved by those close to me to give love to others to avoid excesses and find a middle ground to have one close, loving relationship to have a life that is well-ordered and organized

Module 48 Handout: Values- Things or Concepts You Might Value

Pleasure Popularity Power Responsibility Realism Risk Romance Safety Self-control Self-esteem Self-knowledge Service Sexuality Simplicity Attachment #8 Solicitation No. 110068DC to feel good to be well-liked by many people to have control over others to make and carry out important decisions to see and act realistically and practically to take risks and chances to have an intense, exciting love relationship to be safe and secure to be disciplined and govern my own actions to like myself just as I am to have a deep, honest understanding of myself to be of service to others to have an active and satisfying sex life to live life simply, with minimal needs 183

Stability Strength Spirituality Tolerance Tradition Virtue Wealth World Peace

to have a life that stays consistent to be physically strong to grow spiritually to respect and accept those different from me to follow the patterns of the past to live a morally pure and excellent life to have plenty of money to work to promote peace in the world

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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.

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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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 8. _________________________

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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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 8. _________________________

E. Personal Development Goals: What new attributes do you want to develop in yourself? Strengthen? Decrease? Major Five Year Goal:___________________________________________ Subgoals: 1. __________________________ 3. __________________________ 5. __________________________ Attachment #8 Solicitation No. 110068DC 2._________________________ 4. _________________________ 6. _________________________ 188

7. __________________________

8. _________________________

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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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 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. __________________________ 3. __________________________ 5. __________________________ 7. __________________________ 2._________________________ 4. _________________________ 6. _________________________ 8. _________________________

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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.

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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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