Counselor's Manual for Relapse Prevention With Chemically Dependent Criminal Offenders
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Read the Appendix—Relapse Prevention Work book for Chemically Dependent Criminal Offenders.
If you are a recovering person, you may want to complete the workbook in order to get a better understanding of it. In general, the workbook is in a format that a patient should be able to complete on his or her own. However, a patient's ability to complete the workbook, fully benefit from it, and increase chance of recovery will be much higher if done in a group counseling experience. A separate educational session with a counselor will also increase the patient's ability to recover.
When using the workbook in a group counseling session format, patients complete the exercises on their own, in between group sessions. Patients then present a summary of what they learned by doing the exercises in group sessions. The patients are questioned by the group to ensure that they really understand each exercise and have done it correctly. They receive feedback from the group and then complete the next exercise for the next group session.
If a patient has trouble understanding and completing an exercise, the counselor and the group can help. When assisting a patient in group, it is helpful to complete the assignment on a blackboard so other patients can participate and learn from the exercise.
In some cases it may be necessary for the counselor to help a patient with an exercise in an individual session. This is especially true for the Alcohol/Drug/Legal Calendar (Exercise No. 3) and the Life and Addiction History (Exercise No. 6). Memory problems can interfere with these exercises in some patients. An individual session can be helpful in ordering the recall of old memories.
It is important to have patients bring their workbooks to group, as well as a pad of paper for taking notes. Patients who have reading problems should be teamed with a patient who can read. It is also helpful for these patients to tape record the sessions.
The rest of this part of the book consists of an exercise-by-exercise explanation and instructions to help you assist the patient in using the exercises in an individual or group session.
Purpose. The first section of the patient workbook has two self-tests. The first is the Alcohol and Drug Addiction Test. This test is to identify whether the patient has a problem with alcohol or drugs. It is necessary for the patient to recognize that he or she has a problem before the workbook can help him or her.
Instructions. The primary goal of this test is to get the patient to examine his or her symptoms of addiction and start to make a connection to his or her other legal problems. The patient should complete this test and report the results in group. The group leader should then ask the patient if he or she agrees with the results of the test. Ask the patient how he or she thinks this is related to his or her criminal problems and how he or she has tried to change things.
If the results of the test clearly show that the patient is addicted, but the patient denies it, the counselor should challenge the patient as to why he or she believes the test results are not true. The first three exercises can help the patient connect his or her use with the things that happen to him or her. If, at this point, the patient continues to deny that he or she has a problem with alcohol or drugs, that patient is probably not appropriate for this group and should be referred to a group that deals with basic education about addiction.
If the patient does not show any signs of chemical abuse or addiction, he or she should be referred for non-addiction focused counseling.
Purpose. The second test is for the purpose of helping the offender to see how he or she is similar to other criminal offenders. By helping the offender to see the similarity between himself or herself and others in the group, the person will begin to believe that there is hope. The test will also help the patient to understand the relationship between the use of alcohol or drugs and criminal behavior.
Instructions. The primary goal is to get the patient to start looking at his or her history of criminal behavior and how it is connected to the use of alcohol or drugs. The patient should complete the test and report the results in group. The group leader should then ask the patient whether he or she agrees with the results, and what his or her thoughts and feelings are about the results. Ask the patient how he or she thinks these thoughts and feelings are related to his or her criminal problems and what he or she has tried to do to change things.
Purpose. In this exercise, patients explore why they want to participate in treatment and how motivated they are. This is an opportunity for the group leader to help patients understand that if they are going to recover, they have to make a commitment to long-term change. Long-term change means more than just getting out of their current situation.
Instructions. The goal is to have the group have questions that clearly point out that the patient must have a commitment to long-term abstinence and to a recovery program to successfully stay free of chemical dependency and out of trouble. Have the patient share the contents of this exercise in group. Ask the group to ask the patient if he or she is serious about recovery. If the patient is just trying to get out of a current situation, ask the group to ask the patient what he or she has tried before to get free from different problems and how that has worked.
Purpose. The purpose of this exercise is to help patients determine where they are in the recovery process, and to help you as the counselor decide what a patient should focus on. Patients fall into one of four basic groups.
Transition Patients: These patients do not accept their disease. They believe they can still use alcohol or drugs and learn to control their use. Focus. Connect negative events with alcohol and drug use so that patients can recognize that they need to abstain and begin recovery.
Stabilization Patients: These patients are unable to remain in recovery. Every time they try to stay clean and sober, they get sick, feel crazy, can't think of anything except alcohol or drugs, and encounter many problems. Focus. Identify and learn to manage the thoughts and feelings that make patients return to using alcohol or drugs. Get the patient to ask, "What thoughts and feelings will cause me to use today?"
Early Recovery Patients: These patients cannot get comfortable in their recovery. When they quit, they don't know how to change the way they live so they can enjoy being sober. Focus. Identify and change the things in the patients' lives that interfere with their desire to stay in recovery. Most often, these are things associated with a using lifestyle (friends, family, neighborhood, etc.) that they don't want to give up.
Relapse Patients: These patients get sober and clean, use AA or NA, and enjoy sobriety. However, something happens to make them begin to use again. Focus. Identify what kind of problems make them unhappy with recovery.
Instructions. Have patients report the results of this exercise in their group. Have the group ask each patient what these results meanCwhat do they have to learn in order to recover? Encourage patients to keep their answers in mind as they do the next few exercises, which focus on their history.
Purpose. The purpose of this exercise is for the patient to begin to get a clear picture of his or her history of drug or alcohol use and criminal behavior. The exercise paints this information in picture form on a calendar. Most patients (especially those in early recovery) do not have a clear understanding of their own history and how events or situations in their lives cause other things to happen.
Instructions. Ask patients to present their story (with a calendar) in group. If the patient is unable to do the exercise alone, help him or her in an individual counselor's session or help the patient do the exercise on a blackboard in group. When the calendar is on the blackboard, the patient can copy it into his or her workbook. Have the group ask patients what they learned from the exercise about their history that they previously did not realize.
Purpose. The purpose of this exercise is to help patients identify things they did and did not do in trying to abstain from alcohol or drug use. By beginning to identify the causes of relapse, patients begin to learn how to refocus their thinking on what they can do to change.
Instructions. Have each patient review the worksheets of this exercise in group. Ask the group to question what, if anything, changed after each relapse episode, what was similar each time, and if the patient can identify why attempts to stay clean and sober failed.
Purpose. This exercise helps patients to start to identify patterns that repeat themselves during periods of abstinence. It also helps patients understand that there is a series of events that happen before they relapse. This understanding helps the patient start to see hope of stopping the pattern.
Instructions. Have the patient present the summary worksheet in group. Then ask the group to ask the patient whether there is any pattern that begins to show up, and whether he or she sees any ways the pattern could be changed.
Purpose. Patients use this exercise to begin to get a clear picture of their life. The goal is to identify how their criminal behavior and alcohol and drug use developed over time.
Instructions. Have the patient give a 10-minute talk summarizing his or her life. The talk should track the progress of both criminal behavior and alcohol or drug use in the patient's life. Then ask the group to question the patient about what he or she thinks the major life turning points were and why.
Purpose. This exercise helps patients point to their most important life events and see how they used alcohol and drugs to cope with them.
Instructions. Ask each patient to present the major events in his or her life and describe how alcohol or drugs were used to cope with them. Ask the group to question the patient on how alcohol or drugs helped or did not help the patient to cope.
This chapter lists the exercises that are needed to help patients identify and manage relapse warning signs and develop their own recovery plan.
Purpose. The purpose of this exercise is to help patients identify their alcohol and drug relapse warning signs before they relapse.
Instructions. Because this is a long exercise, it is best to complete it in two or three separate sessions. Have the patients take turns reading the warning signs and their descriptions, as listed in the exercise, out loud in group. After each description, ask the patients to underline words that strike them and that they identify with. Then have the patients talk about any thoughts or feelings that they experienced during the reading.
Purpose. This exercise is to help patients identify their offender relapse warning signs before they return to criminal behavior.
Instructions. Again, it is best to devote two or three sessions to this exercise. Have the patients take turns reading the warning signs and their descriptions out loud in group. After each description, ask the patients to underline words that strike them and that they identify with. Then have the patients talk about any thoughts or feelings that they experienced during the reading.
Purpose. The purpose of this exercise is to help patients identify what is most important about their three major alcohol and drug warning signs and three major offender warning signs.
Instructions. Ask each patient to summarize for the group the warning signs they identified. Then ask the group members to question the patient about whether there is any relationship between the two sets of warning signs. Have the group ask the patient about what he or she became aware of during this exercise.
Purpose. The purpose of this exercise is to help patients recognize how each of the six warning signs looked at in the last exercise happens to them. This exercise also asks patients to look at how the signs might happen in the future. The occurrence of warning signs varies from patient to patient.
Instructions. If necessary, demonstrate how to complete one of these worksheets on the blackboard and ask the patient to complete the rest before the next group session. Ask the patient to review the warning sign analysis worksheets in group, allowing about three minutes for each warning sign. Ask the group members to question the patient about what similarities the patient saw between warning signs, how they were different, and what they learned from the exercise.
Purpose. This exercise combines the warning signs that were evident in the last exercise sheets. The patient will begin to see common warning signs that appear over and over again.
Instructions. It is not necessary for patients to review this exercise in group unless they are having trouble identifying similar warning signs from Exercise No. 11.
Purpose. Patients put the warning signs in the order that they happen.
Instructions. Patients go back to the combined warning sign list in Exercise No. 12 and put the signs in order. It is not necessary for patients to review this exercise in group unless they are having difficulties with the exercise.
Purpose. Patients rewrite the First Ordered Warning Sign List, adding new warning signs in the order they belong. Tell patients that it is important to obtain a new and more complete list.
Instructions. Patients go back to the First Ordered Warning Sign List and add new warning signs in the order that they belong. It is not necessary for patients to review this exercise in group unless they need encouragement or are having difficulties with the exercise.
Purpose. The purpose of this exercise is to help the patient identify which warning signs are the critical ones. Critical warning signs are ones that the patient would recognize when they are happening. These would happen early enough that the patient would be able to do something about them.
Instructions. Have the patient read the three critical warning signs to the group. Ask the group to question the patient about how the patient could recognize these warning signs when they happen, why they occur soon enough to do something about them, and what the patient could do to change the outcome.
Obsession. A thought (usually about alcohol or drugs) that a person has over and over again despite efforts to stop it.
Recovery. The process of rehabilitation that begins with abstaining from alcohol and drugs and continues with changing thoughts, feelings, and actions, which results in major lifestyle and value changes.
Relapse. A series of internal and external events after starting a recovery program that cause a person to collapse physically and/or mentally, return to using alcohol or drugs, or commit suicide.
Relapse justification. A particular thought that a person has to make it okay to return to using alcohol or drugs after starting a recovery program. Example. My life is so miserable anyway, I might as well use.
Purpose. This exercise allows the patient to look at different ways of handling warning signs. This can help to prevent relapse.
Instructions. Ask the patient to read his or her list of warning sign management strategies to the group. Then have the group challenge the strategies by asking "what if" questions.
Purpose. This exercise helps the patient identify the kinds of high-risk situations that may trigger the warning sign on the final warning sign list.
Instructions. Ask the patient to review this exercise in group. Ask the group to question the patient about what the high-risk situations have in common, whether they are on the list of critical high-risk situations, and whether the situations are related to things that happened previously in the patient's life.
Purpose. The purpose of this exercise is to help the patient identify the core or mistaken beliefs that cause the high-risk situation to trigger the warning signs.
Instructions. Have the patient summarize the worksheets in this exercise to the group. Then ask the patient to read aloud the sentence completion portion of the exercise (No. 3). Ask the group members to report any other core beliefs that the patient did not identify.
Purpose. This exercise helps the patients break down mistaken beliefs into specific mandates and injunctions that come up in their lives.
Instructions. Ask the patient to write his or her core beliefs, along with the mandate and injunction lists, on the blackboard. Ask the group to give the patient feedback about any mandates or injunctions that they see in the core belief list that are not already identified, and have the patient add them to the list.
Purpose. This exercise helps the patient to identify mandates and injunctions that they are using that are not true.
Instructions. Ask the patient to read the list of mandates and injunctions one at a time to the group. For each item, ask the patient's opinion as to why it is or is not true. Have the group give the patient feedback on why they believe the item is or is not true and if it is false, what is true instead.
Purpose. This exercise allows the patient to take the information about mandates obtained from the group and identify different ways to handle the mandates in the future.
Instructions. The patient should read the mandate, realize other ways that he or she can think instead, and state what he or she thinks the possible outcomes of thinking in these ways would be. The leader should encourage the group to question the patient on the probability of the outcomes. The patient should reevaluate any unrealistic expected outcomes.
Purpose. This exercise allows the patient to take the information about injunctions obtained from the group and identify different ways to handle the injunctions in the future.
Instructions. The patient should read the injunction, realize other ways that he or she can think instead, and state what he or she thinks the possible outcomes of thinking in these ways would be. The group should be encouraged to question the patient on the probability of the outcomes. The patient should reevaluate any unrealistic expected outcomes.
Purpose. This exercise helps the patient find new ways to handle those mandates and injunctions that are true and create situations where the patient does not see alternative reactions.
Instructions. Have the patient read aloud in group the mandates and injunctions, the alternative behavior, and the possible outcomes of both scenarios. Ask the group members to question the likelihood of the patient being able to carry out the alternative, the reality of the outcomes of this plan. The group should then ask what skills the patient must gain and what tasks he she must complete in order to carry out this plan.
Purpose. Exercise No. 24 helps the patients to pull together all the material that has been worked on so far. Critical high-risk situations that were identified in Exercise No. 17, part 5, are analyzed. The patient then describes different ways of handling the high-risk situations. The patient also lists mandates and injunctions that are associated with these high-risk situations.
Instructions. The patient makes four copies of the exercise to fill out, one for each of the four high-risk situations identified in Exercise No. 17, part 5. The group should give feedback to the patient on the accuracy of the situations and how feasible they think the patient's solutions to handling high-risk situations are. The group should also give feedback to the patient about the mandates and injunctions.
Purpose. The purpose of this exercise is to pull together a set of personal relapse prevention strategies for each personal high-risk situation identified. The patient develops one card for each high-risk situation. The patient will have four cards if he or she identified four high-risk situations, but some patients may want to develop more cards. The patient starts off each day reading the cards and also carries the cards around. This exercise builds on the situations identified in Exercise No. 24, as well as on insights gained in the group process.
Instructions. The patient makes four copies of the exercise to fill out, one for each worksheet completed in Exercise No. 24. The patient also transfers information from the exercise onto cards that are carried around with the patient. Patients may fill out more than four worksheets and four cards if they wish.
Purpose. In this exercise, the patient starts to fill out a daily recovery plan based on what he or she has learned. The purpose of this exercise is to put into action all of the information patients have learned from the previous exercises.
Instructions. Between group sessions, the patient should fill out a daily recovery plan for each day. He or she should review with the group what is working well as part of recovery, and what is not. The group should give feedback on the plan and suggestions to make it work better. (This exercise and Exercise No. 27 should be done simultaneously.)
Purpose. This exercise has the patient fill out an evening inventory sheet reviewing what he or she has learned each day. The purpose of this is to put this information into action.
Instructions. The patient should fill out an evening inventory sheet for each day between group sessions. He or she should review with the group which strategies are working and which are not. The group should give feedback on the strategies and suggestions to make them work better.
When a patient completes the workbook (see the appendix), a closure ceremony should be held as part of a regular group session. During the ceremony all the group members tell the patient how they felt when they first met him or her, how they feel now, and what they wish for him or her in the future. The patient then tells the group members the same. The patient should be encouraged to continue to attend AA or NA and a relapse prevention self-help group.
Each time you work with a patient as a counselor, you will learn more. Every patient after that will be helped by what you have learned. Working with recovering patients can be both frustrating and rewarding. The authors hope that you will grow in your desire and ability to help people recover. Every time you help a person in recovery, you help yourself in some way, too.
As you read these materials, it is hoped that you will see more ways that you can use them. After you become comfortable with the information and techniques, reach out and try new things with this material. Read whatever you can and apply it. Get input and supervision from professionals, if you can do it. You may decide because of your experience that this is something you want to do professionally. If so, look into further education in addiction and general counseling. Everything you learn will help you, and potentially others.
There are a number of words that are used in this manual and in the accompanying patient workbook that you may not be familiar with or that have different meanings than you are used to. The following is a list of terms and definitions as they are used in this publication.
Abstain or Abstinence: To not use any mood-altering substance, including alcohol and drugs.
Addiction: A physical dependence on a drug (alcohol, drugs, nicotine, and caffeine) that is marked by an increased intake, continued use despite consequences, and in many cases, physical withdrawal when use of the drug is discontinued.
Alcoholics Anonymous: An organization of recovering alcoholics who work together to help themselves and others recover from alcoholism.
Awfulizing Sobriety: The belief that living without alcohol or drugs is worse than suffering the consequences of using.
Belief: An idea that a person has about himself or herself and the world, whether it is true or not.
Bio/Psycho/Social: Having to do with the biological or the body, the psychological or the mind, and the social or interactions among people.
Chemical dependency: The same as addiction.
Compulsion: An overwhelming urge to take a certain action despite possible bad consequences.
Core addictive issues: Problems resulting from the period of addictive use that cause problems in sobriety. These include the inability to separate from friends who use, and a lack of acceptance of the need to abstain.
Core psychological issues: Problems resulting from beliefs formed in childhood that continue even though they are no longer true. These beliefs cause a person to act in a self-defeating manner.
Counseling: The process of helping a person understand his or her patterns of thinking, feeling, and acting, and helping that person to make conscious choices to change.
Craving: A powerful physical desire that demands satisfaction.
Detoxification: The process of safely stopping all alcohol and drug use when a person is physically addicted. This may be done by using other drugs and/or by helping the person through social support.
Dysfunctional: Unable to function in a normal manner.
Euphoric recall: The memories of using alcohol and drugs that are associated with pleasant experiences, even if these happened a long time ago.
Feeling: 1. An emotion, such as anger, sadness, or frustration. 2. A body sensation, such as tenseness, stiff neck, or knotted stomach.
Injunction: A mistaken belief in the form of a negative statement to oneself. Injunctions are often not conscious. Example. I can't let myself cry or show my feelings because men don't cry.
Irrational thoughts: Thoughts that do not make sense to a healthy person.
Magical thinking: The belief that alcohol and drugs can help a person do something he or she cannot do without them.
Mandate: A mistaken belief in the form of a compelling statement to oneself. Mandates are often not conscious. Example. I must be in control at all times.
Mistaken belief: An incorrect belief learned in childhood or because of a particular situation that a person continues to believe even though it is not true. This causes the person to feel and act in a way that is inappropriate to the current situation.
Narcotics Anonymous: An organization of recovering drug addicts who work together to help themselves and others recover from addiction.
Obsession: A thought (usually about alcohol or drugs) that a person has over and over again despite efforts to stop it.
Recovery: The process of rehabilitation that begins with abstaining from alcohol and drugs and continues with changing thoughts, feelings, and actions, which results in major lifestyle and value changes.
Relapse: A series of internal and external events after starting a recovery program that cause a person to collapse physically and/or mentally, return to using alcohol or drugs, or commit suicide.
Relapse justification: A particular thought that a person has to make it okay to return to using alcohol or drugs after starting a recovery program. Example. My life is so miserable anyway, I might as well use.
Relapse prevention: The counseling process that helps a person to identify and change thoughts, feelings, and actions that lead him or her back to active chemical dependency.
Relapse warning signs: A series of thoughts, feelings, and actions triggered by a situation or condition that lead from stable recovery back to alcohol or drug use.
Self-defeating behavior: A behavior that a person uses that causes him or her to be worse off than before. Even though the person doesn't like the result, he or she continues the behavior.
Thought: 1. A talk that a person has with himself or herself. 2. A picture or visualization that forms in a person's mind.
Unmanageable feeling: A feeling that a person does not want to have or pretends not to have until the feeling causes a negative reaction.
Gorski, T.T. Passages Through Recovery. Center City, MN. Hazelden Press, 1989.
Gorski, T.T. Understanding the Twelve Steps. New York: Prentice Hall/Parkside, 1989.
Gorski, T.T., and Miller, M. The Management of Aggression and Violence. Homewood, IL: The CENAPS Corporation, 1981.
Gorski, T.T., and Miller, M. Counseling for Relapse Prevention. Independence, MO: Independence Press, 1985.
Gorski, T.T., and Miller, M. Staying SoberCA Guide for Relapse Prevention. Independence, MO: Independence Press, 1986.
Gorski, T.T., and Miller, M. How To Start a Relapse Prevention Self-Help Group. Independence, MO: Independence Press, 1988.
Gorski, T.T., and Miller, M. Mistaken Beliefs About Relapse. Independence, MO: Independence Press, 1988.
Gorski, T.T., and Miller, M. The Staying Sober Educational Modules. Independence, MO: Independence Press, 1988.
Miller, M., Gorski, T.T., and Miller, D.K. Learning To Live Again. Independence, MO: Independence Press, 1982.
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