Transcript The 12 Steps of Alcoholics Anonymous

Betsy F. Amey, LCSW-C
Katharine C. Blakeslee, LCSW-C
The Tuerk Conference, April 17th, 2015
Baltimore, Maryland
Goals of this presentation:
1.
2.
3.
4.
5.
To demonstrate how DBT is an effective treatment modality for
substance use disorders;
To explore how DBT and 12-Step approaches are similar,
following spiritual principles to effect positive changes in those
some have regarded as “hopeless;”
To show the integral role of dialectics/paradoxes of
acceptance/change , confrontation/affirmation, in the recovery
process;
To show how both approaches emphasize progressing from
initial admission of a problem, through several steps, toward “a
life worth living” (learning “the Wisdom to know the
Difference”);
To use an understanding of DBT to further clarify why 12-Step
approaches are so effective (“how it works”)
A Dialectical Stance in the Recovery Process: The
Serenity Prayer
“Lord, Grant me the Serenity to
Accept the things I cannot change;
The Courage to change the things I can;
and the Wisdom to know the difference.”

-- From Reinhold Neibuhr
Problem for Therapists
 “. . . Patients experience both promptings for
acceptance and promptings for change as invalidating
their needs and experience as a whole, with
predictable consequences of emotional and cognitive
dysregulation and failure to process new information.”
(Dimeff & Linehan, 2008)
 Acceptance and Change are equally important.
 Dialectics means that change happens through
dialogue (attraction rather than promotion) By
engaging the opposites, change can happen.
4
4
People who experience the
following - Emotional dysregulation


Affective Lability
Problems with anger
 Cognitive Dysregulation
 Dissociation
 Paranoia
 Interpersonal dysregulation


Chaotic Relationships
Fears of Abandonment
 Self-dysregulation (identity confusion)


Identity Disturbance/difficulties with sense of self
Sense of emptiness
 Behavioral Dysregulation
 Para suicidal behavior
 Impulsive behavior
-- may benefit from DBT
Post-Acute Withdrawal Signs of
Alcoholism/Addiction:
 Difficulty thinking clearly
 Difficulty managing feelings
 Difficulty remembering things
 Difficulty with physical coordination and balance
 Difficulty sleeping restfully
 Difficulty managing stress
 Difficulty staying in touch with reality
from Gorski, Staying Sober: Relapse Prevention Therapy
Linehan’s Biosocial Theory
explains how an individual
develops Emotional
Dysregulation
A PERSON WHO EXPERIENCES
High Sensitivity
+
High Reactivity
+
Slow Return to Baseline
EMOTIONAL VULNERABILITY
Problem symptom patterns
emerge when:
 Person is emotionally vulnerable
 Person is in an invalidating environment
Increased self-invalidation
Is this also what happens to a
person as the addiction
progresses?
Causes? Effects?
 There are biological preconditions for addiction and for




many serious mental illnesses
The biology may cause the sensitivity – AND the brain
changes which occur in the addict/alcoholic heighten
emotional sensitivity
Reactions of others to changes in the addict are often
critical, invalidating
And the addict becomes either more sensitive to or more
denying of the criticism/invalidation (worsening the
symptoms)
This process leads to confusion about “real self”, and the
“self” which is acceptable to others
Dialectics in DBT and in
Addiction Treatment
Dialectical
Dilemmas
Emotional Vulnerability
Unrelenting Crises
Active Passivity
Biological
Social
Apparent Competence
Inhibited Experiencing
Self-Invalidation
Addictive Behaviors Defined
“Addiction . . . includes any repetitive behavior than an
individual is unable to stop, despite the negative
consequences of the behavior and the person’s best
efforts to stop. . .
Some people say that when they engage in addictive
behaviors, they feel “normal” again. In these cases, a
behavior that may have started with positive
reinforcement (gives pleasure) comes to be maintained
by negative reinforcement (stops unbearable distress)”
(Linehan, 2015)
Recovery Demands Living in the
Paradox . . .
 We are powerless
 We are responsible
 Egomaniac
 With inferiority complex
 Surrender . . .
 To win
 It’s not my fault; I have a
 It’s all my fault; I have
disease
done terrible things
DBT demands attention to 3
“polarities”:
The client must . . .
1.
2.
3.
Accept herself as she is in
the moment
Validate her own view of
her difficulties
Pursue getting what she
needs
While also . . .
Changing her thinking and
behavior
2. Validating another person’s
view that she may surmount
these difficulties
3. Losing old ways of getting
what she needs as she
becomes more competent
1.
From Hegel:
Thesis + Antithesis = Synthesis
“An event or idea (thesis) generates its
opposite (antithesis),
leading to a reconciliation of the
opposites (synthesis)”
Reasons to Approach Emotions,
Thoughts, and Value Conflicts
Dialectically
 Allows you to:
 Become aware of conflicts
 Notice third, less damaging possibility
 Make conscious, “intentional decisions, rather than act
automatically
 Compromise, because you see what you are “giving up”
in order to “get”
 Make skillful, “wise mind” choices (not at the extremes)
Reasonable
Mind
Wise
mind
Wise
Mind
Emotional
Mind
DBT -- Skillful Living Assumptions
1.
People are doing the best that they can; and people need to do
better, try harder, be more motivated to change
2.
People may not have caused all their problems; people have to
solve their own problems, anyway.
3.
The lives of emotionally dysregulated individuals are painful
as they are currently being lived.
4.
Emotionally dysregulated people must learn new behaviors in
many of the most important life situations.
More Skillful Living Assumptions
5. There is no absolute truth.
6. People can take feedback as well-meaning rather
than assuming harsh criticism.
7. People generally want to improve.
8. People cannot fail in DBT.
DBT Skills Training
 Teaches clients to “Accept” the situation and the
feelings evoked until they know what to do.
 By using mindfulness skills
 By using distress tolerance skills
 Teaches clients an array of actions they can take to
“Change” (improve) the situation.
 By using emotion regulation skills
 By using interpersonal effectiveness skills
DBT Acceptance Skills
 Mindfulness
 “What” Skills
 “How” Skills
 Distress Tolerance
 Distraction skills
 Improve the moment
skills
 Radical Acceptance
DBT Change Skills
 Emotion Regulation
 Emotion Identification
skills
 Decreasing
Vulnerability to
Emotion Mind skills
 Decreasing Intensity of
Emotion skills
 Interpersonal
Effectiveness
 Requests and Refusals
 Maintaining relationship skills
(validating others)
 Keeping self-respect skills
(validating self)
 Choosing intensity of
communication based on the
situation, not just on emotion
 Starting healthy relationships
and ending destructive ones.
DIALECTICAL ABSTINENCE: A
Relapse Prevention Model
Synthesis of:
 Absolute abstinence whenever one is abstinent even
for a moment
AND
 Harm reduction following every slip even when it is
very small
To the Addict:
“ The dialectical tension here is that, on the one hand,
you have agreed that you value living up to your
potential and building a life worth living, and that your
addictive behavior is incompatible with this goal.
On the other hand, even with this commitment, you
accept that you might have a lapse and once again
engage in the addictive behavior. Thus you need a harm
reduction plan.” (Linehan, 2014)
“Clear Mind” as a replacement for “Addict
Mind” and “Clean Mind” (Linehan, 2014)
“When in “Clear Mind,” make a firm verbal commitment
to abstinence”
ADDICT
MIND
CLEAN
MIND
CLEAR
MIND
Mindfulness for Abstinence
“Urge Surfing”
A plan for abstinence:
1.
2.
3.
4.
5.
6.
7.
Enjoy your success, but with a clear mind; plan for temptations to
relapse.
Spend time or touch base with people who will reinforce you for
abstinence.
Plan reinforcing activities to do instead of addictive behaviors
Burn bridges: Avoid cues and high-risk situations for addictive
behaviors.
Build new bridges: images, smells, and mental activities (urge
surfing) to compete with information associated with craving.
Find alternative ways to rebel.
Publicly announce abstinence; deny any idea of lapsing to addiction.
Maintain abstinence with
“Alternate Rebellion”
When addictive behaviors
are a way to rebel against
authority and the boredom
on not breaking the rules,
try alternate rebellion.
• Shave your head
• Wear crazy underwear
• Wear unmatched shoes
• Express unpopular views
• Do random acts of kindness
• Dye your hair a wild color
Replace destructive
rebellion and keep yourself
on the recovery path.
• Print a slogan on a T-shirt
• Write a letter saying exactly what
you want to
• Etc.
Prepare a Harm Reduction Plan
To put into action immediately after a lapse – “fight with all
your might the “abstinence violation effect.”
Might include:
1. Call your therapist, sponsor, or mentor for skills coaching;
2. Get in contact with other effective people who can help
3. Get rid of temptations; surround yourself with cues for effective
behaviors;
4. Review skills and handouts from your treatment;
5. Practice opposite action for shame. Make your lapse public
among people who will not reject you once they know.
6. Build mastery and cope ahead
Harm Reduction Plan, cont’d.
7. Use Interpersonal Skills to ask for help
8. Conduct a Chain Analysis to analyze what prompted the lapse.
9. Use Problem Solving right away to “get back on the wagon” and
repair any damage you have done.
10. Distract yourself, self-soothe, and IMPROVE the
moment.
11. Cheerlead yourself.
12. Do a pros & cons chart of stopping addictive behaviors or
continuing addictive behaviors.
13. Stay away from extreme (all or nothing) thinking.
14. Keep a list of all your harm reduction behaviors with you all
the time, ready if needed.
Pros & Cons for Distress Tolerance
CHOICES
PROS
CONS
Acting on urges
Pros of acting on urges,
giving in, giving up,
avoiding what needs to
be done
Cons of acting on
impulsive urges, giving
in, giving up, avoiding
what needs to be done
____________________
____________________
____________________
____________________
____________________
____________________
Pros of resisting
impulsive urges, doing
what needs to be done,
and not giving up.
Cons of resisting
impulsive urges, doing
what needs to be done,
and not giving up.
Resisting urges
________________ ________________
________________ ________________
________________ ________________
Maintain Abstinence with Adaptive
Denial
When your mind can’t tolerate craving for addictive
behaviors, try adaptive denial.
1. Give logic a break when you are doing this. Don’t argue
with yourself.
2. When urges hit, deny that you want the problem
behavior or substance. Convince yourself you want
something else.
Be adamant with yourself in your denial and
engage in the alternative behavior.
3. Put off addictive behavior – for 5 minutes, then another 5
minutes, and so on. By telling yourself you will be abstinent
“just for today,” you are saying “I don’t know about forever,
but I can stand this right now.”
Specific Therapist Approaches for
Early Recovery Treatment:
 Commitment: to absolute abstinence (be it only for 20
minutes !)
 Coping ahead
 When relapses occur – promote “failing well”
 Validate effort – avoid shaming
 Hold clients accountable for pushing ahead toward
positive change
“Simultaneously prompting for acceptance and
prompting for change”
Therapist needs the wisdom to know the difference
David Berenson on AA Paradoxes
You must . . .
While also . . .
Put your own sobriety above
everything else
2. Do it totally for yourself,
independent of the bottle
and addictive relationships
3. Understand addiction is not
a moral failing
1.
1.
Caring for others
2. Accepting the help of the
group and/or a personal
Higher Power
3. Taking your moral
inventory, healing character
defects, making amends
Holding the Opposites Until
Synthesis Occurs!
 Addicts are not helpless
 Everyone is “another Bozo on the bus”
 Willingness replaces willfulness
 It’s an addict’s job to arrest the disease, and he needs
and deserves help to do this.
By following “Good Orderly Direction,” we gain “a
new Freedom and a new Happiness”
Radical Acceptance of our Addiction
means “learning to love the
dandelions…”
Bibliography for DBT Presentation, Tuerk Conference,
2015
(Betsy F. Amey, LCSW-C , Katharine Blakeslee, LCSW-C)
1. Berenson, David. (1987) “Alcoholics Anonymous – from surrender to
transformation.” Family Therapy Networker, July/August 1987.
pp.25-31.
2. Daley, D. C. & Marlatt, G. A. (2006) Overcoming your Alcohol or Drug
Problem: Effective Recovery Strategies (pp. 27-33). New York: Oxford
University Press.
3. Dimeff, Linda A. and Koerner, Kelly, ed.(2007) Dialectical Behavior Therapy in
Clinical Practice. New York: Guilford Press.
4. Dimeff, Linda A. and Linehan, Marsha M. (2008)“Dialectical Behavior Therapy
for Substance Abusers.” Addiction Research, June.
5. Goldstein, Eda D. “ Substance abusers with borderline disorders.” In S.L.A.
Straussner (Ed.),(2004) Clinical Work with Substance Abusing
Clients (pp. 370-391). New York: Guilford Press.
6. Gorski, Terence. (1992) Staying Sober: A Relapse Prevention Therapy.
Independence, MO: Herald House.
7. Kabat-Zinn, Jon. (1994) Wherever You Go, There You are: Mindfulness
Meditation in Everyday Life. New York: Hyperion.
Bibliography (p. 2)
8.
9.
10.
11.
12.
13.
Linehan, M. M (2014) DBT Skills Training Manual, Second Edition.
New York:
Guilford Press.
Najavits, L. M. (2006). Seeking safety: Therapy for post-traumatic
stress disorder and substance use disorder. In V. M. Follette & J. I.
Ruzek (Eds.), Cognitive-Behavioral Therapies for Trauma (pp. 228257). New York: Guilford Press.
Orlin, L., O’Neill, M. & Davis, J. (2004). Assessment and intervention
with clients who have coexisting psychiatric and substance-related
disorders. In S. L. A. Straussner (Ed.), Clinical Work with Substance
Abusing Clients (pp.103-124). New York: Guilford Press.
Pederson, L. (2013) DBT Skills Training for Integrated Dual Disorder
Treatment Settings. Eau Claire, WI: PESI.
Tolliver, B. K. (2006). Highlights of the 17th Annual Meeting of the
American Academy of Addiction Psychiatry. Medscape Psychiatry &
Mental Health . http://www.medscape.com/viewarticle/551332.
Van den Bosch, L. M. C. & Verheul, R. (2007). Patients with Addiction
and Personality Disorder: Treatment Outcomes and Clinical
Implications. Current Opinions in Psychiatry, 20(1): 67-71.