TREATMENT FOR SUBSTANCE ABUSE MODULE:

Objectives:

• To provide information about substance abuse and it’s effects.

• To recognize warning signs of an oncoming craving cycle and to directly manage the desire
• To introduce the concept of permanent abstinence: it is the next logical step after attempts to control substance abuse or using have failed.
• Introduction of the concept of unconditional self-acceptance.
• To introduce rational emotive behavior therapy: this involves assessment and implementation of techniques.

Pre group session:

• Choosing a group: 8-10 members

• The counselor conducts a brief interview with each individual member. The aim interview includes the following:

1. Assessment of the level of addiction of each group member using a questionnaire.

2. Briefing about the purpose of the group therapy

3. Motivating the group members for participation in the group therapy.

Session 1:establishing ground rules, building rapport with group members and making them feel comfortable

The purpose of session 1 is for group members to introduce themselves to the group, become comfortable with one another,  and to understand how the group will be run. The members begin to develop relationships with one another, learn what the role of the facilitator is, and begin to find their voice and personal role in the group. The facilitator is encouraged to participate in activities and demonstrate appropriate ways of communicating with others.

In addition, the first session is an appropriate time to implement ground rules for the group.

Activities:

Opening:

The first activity is an energizer or icebreaker, which will serve to get members involved in attaining a co-operative goal with other members. It may also help to ease any tension adolescents may be feeling as they enter this new environment in a positive, healthy way. This can include active games with the boys, and coloring with the girls.

The discussion of the first activity may lead naturally into a discussion of ground rules. If not, this would be an appropriate time to discuss ground rules and confidentiality issues. The initial list may include the following rules. Only positive or encouraging statements, ask for permission to give feedback before giving it, listen openly and quietly while others speak, and members may choose to pass during any activity.

Activity 2:The group member’s view of substance abuse.

This involves generating a discussion about the kind of information the group members have about the different kinds of substances, their effects and the circumstances when they consume substances.

Any one of the following activities can be conducted.

• Encouraging the group members to perform a role-play situation related to substance abuse.

• The group members are encouraged to draw how they feel when they consume substances.

• The group members are encouraged to write a poem related to substance abuse.

• Use a flip chart and ask the group members to brainstorm their views.

Session 2: information, value of life, and creating motivation.

Activity 1:

Energizer and recap of the previous session.

Activity 2:  providing information and facts about substance abuse.

• With reference to the first session, the counselor provides information about substance abuse and their effects by using audio-visual aids, such as tapes, using charts and diagrams.
• Facts about substance abuse: the counselor can make use of statistics and other information about substance abuse.

Activity 3: this activity would encourage group members to become aware of the value of life, and what they desire out of life.

Imagine yourself very old and on your deathbed. Your life is passing before you. Close your eyes. Project your life drama on an imagery screen in front of you. Watch it from it’s beginning up to the present moment. Take your time. After your experience consider:

• What memories bring you the most pain? The most pleasure?
• What experiences, commitments and accomplishments have given meaning to your life?
• Do you have any regrets? If so, what would you have done differently?
• What can you do differently now?
• Do you wish you had spent more time or less time with anyone in particular?
• Were there choices you weren’t aware of? Or perhaps afraid of?
• Did you discover what you value? Are your values what you want them to be?
• Did you discover something you want to change now?

Activity 4: Creating motivation for therapy by using WDEP system

The counselor uses a flip chart and encourages the group members to brainstorm on the following aspects.

• W- wants: what do they want in life?
• D-Decisions: what are the various decisions they have made currently in their life.
• E-self-evaluation: evaluating the efficacy of their decisions
• P-plans: what would be the plans that would lead them to their wants.

Session 3: identifying and AVRT-ing addictive voices

Activity 1:

Recap of the previous session.

Activity 2:AVRT-ing Addictive Voices: addressing the phenomenon of craving.

Guidelines for the counselor:

The counselor demonstrates that, as far as substances and using them is concerned, the thought always precedes the action. Addictive Voice Recognition Technique enables us to recognize warning signs of an oncoming craving cycle and to directly combat the desire to use before it becomes a seemingly overwhelming compulsion.

What once began as a simple desire to get loaded has, in many people, developed into an automatic, involuntary craving. While someone's appetite for drugs or alcohol may be involuntary (like the "need" for oxygen, food, and sex), humans consciously control the fulfillment of that appetite through voluntary muscles in the hands, face, and elsewhere. Hence, it is impossible to become intoxicated apart from the conscious and deliberate decision to do so.

Activity 3: Identification of warning signs of craving cycle.

The counselor encourages the group members to think about their experiences with substance abuse, and brainstorm on the above aspects. The counselor notes them down on a flip chart. This leads to the discussion of the awareness about self-talk and mental imagery.

 Warning signs of an oncoming craving cycle includes the following:

• Auditory thoughts,
• Visual imagery,
• Language,
• And a wide range of feelings.

The counselor communicates to the group members about this voice, and the importance of recognizing this voice. Learning to recognize the voices or imagery when they occur is enough to get stop them for a while.

The counselor also makes group members aware that whenever that "voice" advocates drinking or using other substances, we can make use of certain techniques, which should be combined with a firm commitment to permanent abstinence

The techniques that are useful for averting the craving voices are as follows: the counselor can conduct role-play situations to demonstrate and help the group members learn these techniques.

• Self-talk: What you talk to your self (Self- Talk): Talk to yourself positively. Stop listening to your "cruel inner critic." When you notice that you are doubting or judging yourself, replace such thoughts with self- accepting thoughts, balanced self-assessment and self-supportive direction. The individual can also be instructed to repeat to himself/herself many times in a day positive and encouraging phrases that he/she have identified as helpful to refrain from consuming substances.
• Mental imagery: this would help the group member to  envision and try new ways of thinking and feeling. They might imagine themselves dealing with the craving effectively, and repeating the image to reduce the emotional or cognitive charge to consume substances.
• Thought-stopping technique: it involves saying “stop” either aloud or sub vocally each time the unwanted thought recurs and deliberately replacing it with a more positive thought. Over time, the thought is likely to diminish in frequency and intensity.

Session 4: permanent abstinence.

Activity 1:

Recap of the previous session.

Activity 2:Permanent Abstinence: “I will never drink or use again”

The counselor communicates this by using the following guidelines:

While saying "never" can be disconcerting at first, we think it is much more effective, in the long run, to get used to the idea of permanent abstinence right from the start. After all, permanent abstinence is the next logical step after attempts to control our drinking or using have failed.

We can learn much about our addiction if we repeatedly declare our commitment to permanent abstinence. When we say, "I will never drink or use again," the part of us that wants to continue objects very loudly. This gives us an excellent opportunity to observe our attitudes, beliefs, and conditioning. Often we will see the rationalizing ourselves in order to justify drinking and using. We can see how we "give ourselves permission" to drink and use with ideas that center around pleasure seeking, problem solving, relief, and escape.

The counselor communicates that the most important causes of our addictions and dependencies are our thoughts, attitudes, images, memories, and other cognitions -- not our experiences. If we blithely tell ourselves, "just for today," the desire to use may just wait until tomorrow. The dysfunctional thinking might not show itself and we may never learn to challenge those beliefs.

Activity 3: building contract.

The counselor can use the following series of questions, which is an efficient framework for the contract building process.

1. Do you want to give up substance abuse would enhance your life?
2. What would you need to change in order to get what you want?
3. Are there any changes that you could make in yourself that would enhance your life?
4. What would you be willing to do to effect the change?
5. How will other people know when the change has been made?
6. How you might sabotage yourself?

Session 5: Unconditional Self-Acceptance:

Activity 1: Winner/loser continuum:

Judging from how you feel about yourself, what you have accomplished in your life, and what you relationship \s are with others, are yourself somewhere along the continuum. Think of one end of the continuum as a tragic loser and the other end as a totally successful winner.

How do you feel about yourself?

Loser_____________________Winner

How do you feel about what you have accomplished in your life?

Loser______________________Winner

How do you feel about your relationships with others?

Loser_____________________Winner

Are you satisfied with where you yourself?

If not, what would you like to change?

Activity 2: Strengths analysis:

The group members are encouraged to think about their strengths and weaknesses. The aim of this activity is to make them aware and value their strengths and foster unconditional self-acceptance in them.

Activity 3: Based on the above activities, the counselor can use the following guideline to communicate the concept of unconditional self-acceptance:

External measures of individual worth are not the same as one's intrinsic worth: the value one places on oneself. Since there is no scale with which to rate myself, I can rightly and accurately declare my value as a human to be infinite. Mine is the final word on this matter. My value rests entirely on the fact that I exist. I love myself simply because it feels better than self-loathing; I need no other reason to accept myself.

I did not want to get clean and sober in order to become a worthwhile person. It is precisely because I am a worthwhile person that I choose to get and stay clean and sober. If I love myself, it is unlikely that I will do things that may harm me. If I am prone to becoming depressed or entering into a self-destructive state of mind, however, I may need additional tools.

Activity 4: Setting goals:

Following this, the goals for therapy are decided for the group members, which are understandable, objective, realistic and achievable.

Activity 5: group song/slogan

The counselor can encourage the group members to come up with a slogan or a song, which symbolizes their worth as individuals and also remind them of their commitment towards permanent abstinence.

Session 6: Beginning of rational emotive behavior therapy:

Drug and alcohol abusers often display characteristics that center around automatic, non reflective yielding to impulses; sensitivity to unpleasant feelings; diminished perspectives of the future; insufficient motivation to control one's behavior; and "Low Frustration Tolerance." We can deal with these traits on our own using Rational-Emotive Therapy (RET).

With RET, we can identify and control many extreme, irrational states of emotion. If an idea is making one miserable, this is a good indicator that that idea is irrational. When one is upset, no matter how logical and realistic your point of view may seem, there is probably an irrational idea somewhere that needs to be dealt with. Irrational ideas are usually anxious, demanding, absolutistic, and unconditional; irrational beliefs hardly ever have a "Plan B."

Many people who drink or take drugs also suffer bouts of extreme emotional reactions to everyday stresses. If drinking appears to minimize these problems, we can expect them to return once the user becomes abstinent. Also, if the user was intoxicated all the while his or her peers were learning everyday coping skills, he or she may need to learn those skills for the first time.

To discover how an irrational idea can affect our emotional well-being, we work the ABC's of RET. 

• First, we note our feelings or emotional state -- what we call the Consequence.
• Then we find an event, external or internal, that appears to have caused us to feel that way -- the Activating Event.
• We write what we think about the activating event -- our Beliefs. Finally, we Dispute each belief: Can I prove it is true? Can I prove it is false? Can abandoning or replacing this idea help me? Could keeping this idea harm me? What usually results is called the Effect -- a new emotional consequence.

A useful way to illustrate this triple approach to causation is by using Ellis’ ‘ABC’ model. In this framework

 ‘A’ represents an activating event or experience and the person’s inferences or interpretations about the event;

 ‘B’ represents their beliefs about the event;

 ‘C’ represents the consequence – the emotions and behaviors that follow from those thoughts and beliefs.

A typical REBT interview

 Here is how an interview based on the ABC model would usually progress:

1. Review the previous session’s homework. Reinforce gains and learning. If not completed, help the client identify and deal with the blocks involved.
2. Establish the target problem to work on in this session.
3. Assess the ‘A’: what happened, when did it last occur? What did the client infer was happening or would result from what happened?
4. Assess the ‘C’: specifically what unwanted emotion did the client experience, and how strong was it?
5. Identify and assess any secondary emotional problems (inappropriate negative emotions about having the problem, for example shame about feeling grief).
6. Identify the beliefs – ‘B’ – causing the unwanted reactions, especially demandingness, awfulising, discomfort-intolerance, and people-rating.
7. Connect ‘B’ & ‘C’ (help the client see that their unwanted reaction resulted from their thoughts).
8. Clarify and agree on the goal – ‘E’: how does the client wish to feel (and behave) when next confronted with a similar ‘A’?
9. Help the client dispute their beliefs, preferably using ‘Socratic questioning’ (‘Where is the evidence ... ?’ ‘How is it true that ... ?’ ‘Where is it written that you must ... ?’ etc. Replace beliefs that are agreed to be irrational.
10. Plan homework assignments – ‘F’ – to enable the client to put their new rational beliefs into practice. Identify and deal with any potential blocks to completion of the homework.

Techniques:

Cognitive techniques

• Rational analysis: analyses of specific episodes to teach the client how to uncover and dispute irrational beliefs (as described earlier). These are usually done in-session at first; then, as the client gets the idea, they can be done as homework.
• Double-standard dispute: If the client is holding a ‘should’ or is self-downing about their behaviour, ask whether they would globally rate another person (e.g. best friend, therapist, etc.) for doing the same thing, or recommend that person hold their demanding core belief. When they say ‘No’, help them see that they are holding a double-standard. This is especially useful with resistant beliefs which the client finds hard to give up.
• Catastrophe scale: this is a useful technique to get awfulising into perspective. On a whiteboard or sheet of paper, draw a line down one side. Put 100% at the top, 0% at the bottom, and 10% intervals in between. Ask the client to rate whatever it is they are catastrophising about, and insert that item into the chart in the appropriate place. Then, fill in the other levels with items the client thinks apply to those levels. You might, for example, put 0%: ‘Having a quiet cup of coffee at home’, 20%: ‘Having to mow the lawns when the rugby is on television’, 70%: being burgled, 90%: being diagnosed with cancer, 100%: being burned alive, and so on. Finally, have the client progressively alter the position of their feared item on the scale, until it is in perspective in relation to the other items.
• Devil’s advocate: this useful and effective technique (also known as reverse role-playing) is designed to get the client arguing against their own dysfunctional belief. The therapist role-plays adopting the client’s belief and vigorously argues for it; while the client tries to ‘convince’ the therapist that the belief is dysfunctional. It is especially useful when the client now sees the irrationality of a belief, but needs help to consolidate that understanding. (NB: as with all techniques, be sure to explain it to the client before using it).
• Reframing: another strategy for getting bad events into perspective is to re-evaluate them as ‘disappointing’, ‘concerning’, or ‘uncomfortable’ rather than as ‘awful’ or ‘unbearable’. A variation of reframing is to help the client see that even negative events almost always have a positive side to them, listing all the positives the client can think of (NB: this needs care so that it does not come across as suggesting that a bad experience is really a ‘good’ one).

Imagery techniques

• Time projection: this technique is designed to show that one’s life, and the world in general, continue after a feared or unwanted event has come and gone. Ask the client to visualise the unwanted event occurring, then imagine going forward in time a week, then a month, then six months, then a year, two years, and so on, considering how they will be feeling at each of these points in time. They will thus be able to see that life will go on, even though they may need to make some adjustments.
• The ‘blow-up’ technique: this is a variation of ‘worst-case’ imagery, coupled with the use of humour to provide a vivid and memorable experience for the client. It involves asking the client to imagine whatever it is they fear happening, then blow it up out of all proportion till they cannot help but be amused by it. Laughing at fears will help get control of them.

Behavioral techniques

One of the best ways to check out and modify a belief is to act. Clients can be encouraged to check out the evidence for their fears and to act in ways that disprove them.

• Exposure: possibly the most common behavioural strategy used in REBT involves clients entering feared situations they would normally avoid. Such ‘exposure’ is deliberate, planned and carried out using cognitive and other coping skills. The purposes are to (1) test the validity of one’s fears (e.g. that rejection could not be survived); (2) de-awfulise them (by seeing that catastrophe does not ensue); (3) develop confidence in one’s ability to cope (by successfully managing one’s reactions); and (4) increase tolerance for discomfort (by progressively discovering that it is bearable).
• Shame attacking: this type of exposure involves confronting the fear of shame by deliberately acting in ways the client anticipates may attract disapproval (while, at the same time, using cognitive and emotive techniques to feel only concerned or disappointed). For example, you could get the client to switch their shoes to the wrong feet then walk round the office building with you for ten minutes or so, at the same time disputing their shame-inducing thinking.
• Risk-taking: the purpose is to challenge beliefs that certain behaviours are too dangerous to risk, when reason says that while the outcome is not guaranteed they are worth the chance. For example, if the client has trouble with perfectionism or fear of failure, they might start tasks where there is a reasonable chance of failing or not matching their expectations. Or someone with a fear of rejection might talk to an attractive person at a party or ask someone for a date.
• Paradoxical behaviour: when a client wishes to change a dysfunctional tendency, encourage them to deliberately behave in a way contradictory to the tendency. Emphasise the importance of not waiting until they ‘feel like’ doing it: practising the new behaviour – even though it is not spontaneous – will gradually internalise the new habit.
• Stepping out of character: is one common type of paradoxical behaviour. For example, a perfectionistic person could deliberately do some things to less than their usual standard; or someone who believes that to care for oneself is ‘selfish’ could indulge in a personal treat each day for a week.
• Postponing gratification is commonly used to combat low frustration-tolerance by deliberately delaying smoking, eating sweets, using alcohol, sexual activity, etc.
• Skills training:  relaxation, social skills.

Session 7: wrap up and Termination.