4th – 5th Step Workshop

Greg Gable, PsyDScott Teitelbaum, M.D., FASAMKen Thompson, M.D. , FASAM

INTRODUCTIONKen Thompson

Introduction

• Relapse is associated with personality disorders in physicians• Depth and power of 12 steps often underestimated by

professionals• 4th step gives clues to characterologic traits which are

formative of personality styling• Relapse is associated with not doing a thorough 4th step by

self report• 4th step is useful to process resentments, a known relapse

trigger• Useful clinical information is gleaned from group 4th- 5th step

work

RELEVANT RESEARCH & PSYCHOLOGICAL OBSERVATIONS

Greg Gable

Relevant Research

Risk factors for relapse included: Family history of substance use disorder Opiate use in the context of a comorbid psychiatric

disorder Comorbid psychiatric disorder (Largely on Axis I)

Domino, Karen B. MD, MPH; Hornbein, Thomas F. MD; Polissar, Nayak L. PhD; Renner, Ginger; Johnson, Jilda; Alberti, Scott; Hankes, Lynn MD, 2005

Relevant Research

• Cohort of 292 subjects•107 with comorbid diagnosis

– 100 with comorbid Axis I diagnosis– 5 with comorbid Axis II diagnosis– 2 with both

Domino, Karen B. MD, MPH; Hornbein, Thomas F. MD; Polissar, Nayak L. PhD; Renner, Ginger; Johnson, Jilda; Alberti, Scott; Hankes, Lynn MD, 2005

Relevant Research

• 60.3% of assessed physicians suffered from comorbid SUD and psychiatric disorders

• 56.8% with Axis II disorder• 54.5% with Axis I mood disorders• 34.1% combined• 18.2% anxiety disorders

Angres, McGovern, Rawal, Purva, & Shaw, 2002

Relevant Research

•Physicians with comorbid diagnoses:• Did as well in treatment as controls• Seemed to have equivalent treatment outcomes at

follow up• Seemed to report greater degrees of emotional

distress even when engaged in a stable recovery

Angres, McGovern, Rawal, Purva, & Shaw, 2002

Gable 2002

Relevant Research

• 308 physician cohort• 78 physicians with relapse (25%)• 230 physicians with no relapse (75%)

• 78 physician relapse population• 55 physicians reengaged in monitored recovery• 92% of original cohort in monitored recovery of at least

5 years

Gable 2002

Relevant Research

Time to First RelapseYear of relapse f % _____ <1 11 22% 1-5 25 48% 5-10 10 20% >10 4 8%_____

Gable 2002

Drug of ChoiceRelapse Non-relapse

Opioid 23 46% 22 44%

Non-opioid 27 54% 28 56%

Gable 2002

Relapse Relevance

Condition relapse non-relapse

Abuse * 26 52% 22 45%Family SUD 30 61% 37 75%Eating Disorder 10 20% 11 21%

Compulsive Behaviors 15 30% 11 21%_________________

* Emotional/Physical/Sexual Abuse

Gable 2002

Relapse Relevance

• The presence of an Axis II disorder was strongly related to relapse

– (χ² = 16.071, df = 1, p<.05) (46% of the relapse group had an Axis II diagnosis, compared to eight percent of the non-relapse group). (p actually computed as .000)

Gable 2002

Relapse RelevancePersonality Disorder Diagnosis

Diagnosis relapse non-relapseOCPD 4 8% 0 0% NPD 2 4% 0 0%

BPD 2 4% 0 0%

PD NOS 15 30% 4 8%

Gable 2002

Relapse Relevance

• The presence of a comorbid Axis I diagnosis was significantly related to relapse – ( χ² = 9.180, df = 1, p<.05). (p computed to .002)

Gable 2002

Relapse relevance

Axis I disorder relapse non-relapse

Bipolar 6 12% 1 2%MDD 12 24% 7 14%Dysthymic 1 2% 2 4%Bulimia 3 6% 3 6%PTSD 1 2% 1 2%Anxiety/Panic 3 6% 0 0%OCD 1 2% 0 0%Sexual 1 2% 0 0%ADHD 1 2% 0 0%(43% of overall sample had a comorbid Axis I dx)

Gable 2002

Relapse Relapse

• When the presence of an Axis II disorder is combined with the presence of an secondary Axis I disorder (not including secondary substance use disorder diagnoses), the presence of a co-occurring psychiatric disorder on Axis I or Axis II was strongly related to relapse (χ² = 23.645, df=1, p<.05). (p actually computed to .000)

Gable 2002

Relapse Relevance

Relapse Status f % of group

Relapse 41 82%No Relapse 17 34%

Note: Comorbid secondary substance use disorders are not included

Project Match Data

• Compared CBT, MET, and TSF• Months 4 to 15 Sobriety

– CBT = 15%– MET = 14%– TSF = 24%

• The advantage of TSF endured through the 12 month follow up period (NIAAA)

Personality/Relational Issues as Relapse Factor

Presence of relational difficulties presents barriers to effective long-term use of tools

Traits increase relapse risk because: Less assiduous use of tools Pt. can revert to pre-recovery coping mechanisms at

times of heightened emotional stimulation (positive or negative)

Learned use of tools over time can decay

Diagnostic Issues

• Danger in diagnosing personality disorder too early in treatment process

• Danger in diverting patient focus from addiction to “psychological issues”

• Tendency to postpone addressing of these issues in favor of recovery tools/comparing in.

Implications for Treatment/Recovery

• Trauma often a factor• Important to help patient identify the trauma

and importance for working with it over time• Important not to avoid trauma material in

treatment• Unresolved/undisclosed trauma can prevent

honest sharing with others

Case Study Sarah

• Internist• Treated in long-term residential• Relapsed soon after to meds not covered on HP

panel (after researching this)• Flew under radar for over a year, then relapse

became visible• Returned to long-term residential treatment• Personality issues, cluster B a problem in

treatment

Case Study Sarah

• Discharged early because of rule violations• Struggled in outpatient, willful, not accepting

of treatment plan• About 8 months after second tx experience,

began to show changes• When interviewed, identified sponsor and 4th

step as change agent

Case Study Sarah

• Mary identified a character defect as having been central to her difficulty in recovery

• When asked to name this defect, she did not describe narcissistic, borderline or antisocial traits.

• She talked about becoming aware of her intolerance, lack of acceptance

• This construct was, for her, something to build change upon.

Project Match Data

-Compared CBT, MET, and TSF-Months 4 to 15 Sobriety

CBT = 15%MET = 14%TSF = 24%

The advantage of TSF endured through the 12 month follow up period (NIAAA)

What we have learned

• Important to bring the traits into awareness • Important to make work on the traits part of the

treatment/recovery plan• Important for clinicians to communicate to other

providers about presence and potential effects of traits

• Not important to have pt. arrive at acceptance of a specific diagnosis

What have we learned?

• Identifying trauma and characterologic issues early as possible is important

• 4th step and enneagram are helpful in bringing relapse issues into the light

• It is not so important to diagnose except to communicate with other treaters

• People are willing to get rid of things that they deem as non-functional.

• On going attention to this by “monitoring” groups might be important – group 4th step work and or enneagrams might be useful

DEPTH & POWER OF STEPS 4, 5, 6 & 7Scott Teitelbaum

Depth of the Steps

• Underestimated by many professionals• More than just meetings• Ability to assess personality styling• Open the door to transformation of

personality

Spiritual Principles – Psychiatric Counterparts

• Step 1 – honesty• Step 2 – hope• Step 3 – faith• Step 4 – courage• Step 5 – integrity• Step 6 – willingness• Step 7 – humility• Step 8 – brotherly love• Step 9 – justice• Step 10 – perseverance• Step 11 – spirituality• Step 12 – service

Resentments

• “For when harboring such feelings we shut ourselves off from the sunlight of the Spirit. The insanity of alcohol returns and we drink again. And with us, to drink is to die”.

• Common cause of relapse• Reflects a deep spiritual problem• Fear and hurt underlie the anger

4th Step

• Personal Inventory• Explores - resentments, fears, wounds, secrets• Looks for character defects to remove• Can be used as a diagnostic tool?

4TH STEP BY THE COLUMNSKen Thompson

4th Step – 4 columnsI’m resentful at The cause Affects my Character defects

I’m resentful at The cause Affects my Character defects

Father

Bob - peer

I’m resentful at The cause Affects my Character defects

Father UnemotionalHigh expectationsNever attended any of my sports activitiesPhysically abusive

Bob Attention to my wifeDid not pay money he owedTook my job

“ The Ouch”

“Spiritual Wound”

I’m resentful at The cause Affects my Character defects

Father UnemotionalHigh expectationsNever attended any of my sports activitiesAlways at workPhysically abusive

Self esteemSense of comfortSecurity

Bob Attention to my wifeDid not pay money he owedTook my job

Sex relationsFinancial security

“Spiritual Wound”

I’m resentful at The cause Affects my Character defects

Father UnemotionalHigh expectationsNever attended any of my sports activitiesAlways at workPhysically abusive

Self esteemSense of comfortSecurity

Emotionally distantPerfectionisticEntitled

Bob Attention to my wifeDid not pay money he owedTook my job

Sex relationsFinancial security

Wrath, vengefulLust

Personality Styling

Self centered fear

Move on to steps 5, 6, & 7

“ The Ouch”

Common Doctor Defects

• Perfectionism• Care taking• People pleasing• Intellectualism• Arrogance-entitlement• Workaholism

OBSERVATIONSKen Thompson & Scott Teitelbaum

I’m resentful at The cause Affects my Character defects

Father UnemotionalHigh expectationsNever attended any of my sports activitiesAlways at workPhysically abusive

Self esteemSense of comfortSecurity

Emotional distantIsolativeArrogantEntitled

Bob Attention to my wifeDid not pay money he owedTook my job

Sex relationsFinancial security

Wrath, vengefulLustGreed

May not see the resentment or too ashamed to address it

May continue to justify the behaviors Do not see connection to “wound”Do not see them as still active in life

May not feel the ouchNot able to see impact on securityNot able to see the fear

May negate the resentment since they realize they did something wrong as wellNot emotionally connected

The Barriers to a 4th step

CASE STUDIES

BARRIERSAll of us

Barriers

• Religious perceptions• Morality as issue • Lack of understanding of 12 steps

WHAT WE HAVE LEARNEDGreg Gable, Scott Teitelbaum, Ken Thompson

Diagnostic Issues

• Danger in diagnosing personality disorder too early in treatment process

• Danger in diverting patient focus from addiction to “psychological issues”

What we have learnedCharacter Defects

• Require energy to maintain• Driven by “wound”• Create distress• Distress may look like anxiety, depression• Attempts to medicate is common (by client

but also by “psychiatrists”)

What we have learned

• Important to bring the traits/defects into awareness

• Important to make work on the traits part of the treatment/recovery plan

• Important for clinicians to communicate to other providers about presence and potential effects of traits/defects

• Not important to have pt. arrive at acceptance of a specific diagnosis

What have we learned?

• Identifying trauma and characterologic issues early as possible is important

• 4th step is helpful in bringing relapse issues into the light

• People are willing to get rid of things that they deem as rotten.

• On going attention to this by “monitoring” groups might be important – group 4th 5th step work

THE FUTURE

The Future

• Operationalizing group – captive audience in monitored physician groups

• Encouragement of working steps – possible reduction in relapse

• Ability to see changes in recovery trajectory

Operationalizing

• Method of the group• Findings by consensus• Measurable components of the 4th- 5th step

group