Four Paradigms of Recovery A Criterion Counseling Model for Successfully Overcoming Addiction H....

Four Paradigms of Recovery A Criterion Counseling Model for Successfully Overcoming Addiction

H. Gray Otis, PhD, CMHC, DCMHS-TClinical Director, The Phoenix Recovery Center

[email protected]

www.ThePhoenixRC.com

801-885-8585

Copyright H. Gray Otis, PhD, CMHC, 2013

Clinical Director, Clinical Mental Health Specialist - Trauma

The Phoenix Recovery Center

Residential recovery treatment for men & women

The Phoenix Counseling Center

Intensive outpatient recovery treatment

General outpatient – adults, couples, families

Professional Background


How do we assess successful recovery?

We know the criteria in order to diagnose substance dependence

Do we know what recovery is? What are the criteria?

What does “dual diagnosis” recovery mean?

Can we define behavioral health by the absence of symptoms?

Genesis


My clinical concentration is on abstinence but there are other options Focus of treatment

Addiction recovery Trauma & chronic distress resolution Health and strength development

Medications alleviate symptoms – but – do not resolve underlying causal factors

Substance dependence is a biological disease with underlying psychological origins – thus – dual diagnosis

Bias – Up Front Presumptions


Recovery Perspective

Treat the Addictions• Consider the symptoms of addictions – substance & behavioral• Could an addiction be symptomatic?

Treat the Underlying Causal Factors• Understand the unseen factors that created the addiction• These are often based in trauma or chronic distress

Encourage health & strength development


RESEARCHWhat are the percentage of clients that as teens experimented with drugs or alcohol and then got hooked?

Is this primary basis that explains why they became addicted?

Does the public believe that drug experimentation is the reason teens become addicted?


CURRENT RESEARCHWhat are the percentage of clients that as teens experimented with drugs or alcohol and then got hooked?

Is this primary basis that they became addicted?

Does the public believe that drug experimentation is the reason teens become addicted?

Current research addiction is based on:

1. Exposure

2. Vulnerability of the individual – genetic predisposition, past distress

3. Current situation of the individual – present distress


Factors of Psychological Health

Those who are generally healthy have:1. Positive Self-beliefs

2. An Internal Sense of:

• Emotional self-regulation

• Nurturing self-care

3. Effective Interpersonal Relationships

4. Perspective of Purpose and Meaning


Those in long-term recovery exhibit:1. Positive Self-beliefs

Believe

2. An Internal Sense of:Understand

• Emotional self-regulation


3. Effective Interpersonal Relationships Connect

4. Perspective of Purpose and Meaning Imagineer

Four Paradigms of Recovery


Believe – Understand – Connect – Imagineer

The Four Paradigms of Recovery serve as a model to

integrate clients’ positive experiences which they had before their addiction with

current constructive recovery experiences.

This model correlates with Twelve Step principles.

Synopsis

BelieveOur Self-Beliefs Govern Life Choices & Outcomes


“I am unworthy to be loved”

Virtually everyone in initial recovery does not accept that they are worthy of being loved .

In many cases, this is the underlying reason for their dependence.

BELIEVE


“I am unworthy to be loved”

Virtually everyone in initial recovery does not accept that they are worthy of being loved .

In many cases, this is the underlying reason for their dependence.

Substance or Behavioral Dependence

Shame Self-Beliefs

BELIEVE


DEFINING SELF-BELIEFSM

ore than persistent personality traits

How the person experiences self - for exam

ple;

You alone see through your eyes and only you interpret w

hat you perceive

No one w

ill ever experience what

you have – your unique com

bination of experiences

You daily construct your own

unique world

This always links to w

hat you believe about your self

Our self-beliefs essentially shape who we are


Individuals fall into one of two groups

Those individuals who deeply

believe:

“I am unw

orthy to be loved”

‘I am not enough and never will be.’

‘I am asham

ed of myself’

‘I cannot stand who I am so I num

b m

yself with food, addictions, ‘right’ thinking, m

eds, anger, etc.

How

does this correlate with those

who suffer from

substance addiction?

RESILIENCE RESEARCH


Other Shame Self-BeliefsI don’t deserve love

I am a bad

I am worthless

I deserve bad things

I am damaged, broken

I am ugly

I am stupid, not smart enough

I don’t matter

I don’t belong, I am different

I am irresponsible

I cannot be trusted, trust myself

I cannot trust others

I am weak, not in control

I am a failure

I am imperfect, flawed, I must please


UNDERSTANDING SHAME•

Shame self-beliefs distort and

disfigure how individuals

perceive themselves.

•Evidence is accum

ulated that

the shame beliefs are true

•The psychic pain of sham

e

dominates consciously and

subconsciously e.g.

destructively disparaging self-

talk

Shame is the petri dish in

which the bacteria of

addiction thrive


Distinguishing between guilt and shame

Guilt:

“I did something wrong or bad,” “I did something dumb,” “I acted carelessly,” etc.

Guilt motivates us to change

SHAME SELF-BELIEF QUALITIES



Guilt:



Shame:

“There is something wrong with me – I am bad,” “I am dumb,” “I am careless,” etc.

Shame beliefs lead us to accept the lie that we cannot change




Guilt:



Shame:

“There is something wrong with me – I am bad,” “I am dumb,” “I am careless,” etc.

Shame beliefs lead us to accept the lie that we cannot change

Counselors must be skilled in shame resolution



THE SELF-BELIEF CONTINUUM Fear/Sham

e

Love/Empathy

1 2 3

4 5 6

7

On a scale from

1 to 7, how much

of the individual’s life is

lived with love and empathy?

Low scores correlates with shame

self-beliefs & addictions


ORIGINS OF SHAME SELF-BELIEFShame self-belief arises from emotionally charged events (trauma) as well as other disturbing experiences (small t trauma, chronic distress, developmental trauma)

The individual lives with distress such as a loss of attachment, fear for the safety of self or others, chronic low-grade anxieties, cultural conflicts, feelings of inadequacy, etc.

There is often a sense of terrible helplessness

These deep seated emotions may be manifested in almost any DSM disorder and all substance dependence disorders

In order to blunt the high level of fear & shame, individuals use coping mechanisms that provide instant, temporary relief – most commonly substance or behavioral addictions


SHAME SELF-BELIEF RESULTSShame self-belief induces negative coping mechanisms

In addition to drugs and alcohol, individuals may turn to sex, gambling, working, religion, blaming, exercise, politics, eating disorders, or any other addiction patterned behaviors

Shame Self-Beliefs most often lie in the subconscious

Self-beliefs trump everything else mentally & emotionally – they color are decision making

We must go beyond cognitive-behavioral therapy

’Counselors can create the pre-conditions for transforming Shame Self-Beliefs into Positive Self-Beliefs


The second of the two groups :

Those individuals who

predominantly believe:

“I am w

orthy to be loved”

How many individuals with

addictions have this self-belief?

What can w

e learn from this?

POSITIVE SELF-BELIEFS


Counselors need an evidenced-based m

odel to understand the underlying basis of m

ental disorders including substance dependence:

“Client sham

e self-beliefs relate to attachm

ent, abandonm

ent, and trauma”

Shame Self-beliefs can be

transformed into Positive

Self-beliefs

Outcom

e research shows that addressing underlying sham

e is a critical aspect dependence recovery.

THE TRANSFORMATIONAL APPROACH


“I am evil”“I am acceptable!”

Shame self-belief example:

‘I am evil’ replaced with:

What are the chances for his recovery?

TRANSFORMATIONAL SELF-BELIEFS


TRANSFORMATIONAL APPROACHShow clients how to transform ‘Shame Self-Beliefs’

1. Develop Client Emotional Regulation

2. Treat Trauma

3. Promote Positive Self-Beliefs

4. Support Forgiveness, No Use of Labels, Self-Change, Addiction Recovery

Which comes first?


THERAPEUTIC CONSIDERATIONSSeek out shame beliefs:

“What are you ashamed of?” “What traumatic or chronic distress experiences have you had?” (e.g. abuse,

accidents, injuries, combat, learning difficulties, bullying, alcoholic caregiver, etc.) “What negative beliefs do you have about yourself starting with the words; ‘I am. . .’?

(e.g. “I am unsafe,” “I’m stupid,” “I am out of control,” I’m a terrible parent,” etc.)

Distinguish for the client the difference between guilt and shame

Help clients transform shame self-beliefs into positive self-beliefs – Brene Brown (TED Talk - Vulnerability, etc.)


TREAT TRAUMA & CHRONIC DISTRESS

Trauma & attachment are at the center of shame self-belief - understand GAD, PTSD, small t trauma, mTBI, developmental trauma

Know how to help client’s effectively process trauma – evidenced based optionsBody workEMDRSand tray, play therapyThought Field Therapy, Acupressure Tapping, (Instant Emotional Healing, Lambrou & Pratt), Affirmations Cognitive Processing TherapyTrauma Focused CBTStress Inoculation TherapyOthers?

Ethical responsibility to effectively treat or to refer


EFFECTIVE TREATMENTResults – positive self-beliefs become dominant

1. Individuals convert shame self-beliefs to positive self-beliefs and they know it

2. Triggers are no longer experienced

3. The shame experiences are integrated in memory

4. The results are permanent

The impact of life-threatening industrial accident on Nate

Chronic distress or trauma is more difficult for many clients to resolve – Belinda’s story


STRENGTHENING SELFPracticed 12-15 times a day for 7 weeks

Positive Self-Belief elements:

1. Strong positive emotional memory visualization

2. Body memory sensation

3. Belief: “I am worthy to be loved!”

4. Finger to thumb connection

Demonstrated by the counselor – five iterations

Client logging method

Client preparation: “The toughest experiment you will ever do”

Client reports back at the next session


OUTCOMES OF POSITIVE BELIEF Alleviation of root source of substance dependence

Enhanced emotional resilience

Better physical well-being

Improved relationships

Increased appreciation, enjoyment, & meaning

Lasting recovery outcomes

Understand• Emotional self-regulation



EMOTIONAL SELF-REGULATIONVirtually all people afflicted with dependence have used substances and behaviors to numb out painful emotionsWithdrawal usually brings an immense increased of often overwhelming

emotions and feelings

Most do not have a vocabulary to describe what they are experiencing

They feel flooded with unwanted emotional pain

“We are swimming in a sea of our own emotions”


THERAPEUTIC CONSIDERATIONSTeach an easy-to-understand emotional vocabulary

Distinguish between secondary emotions (e.g. “I am mad”) from primary

feelings (e.g. I feel Accused, Guilty, Rejected, Unlovable, and/or Powerless)

so that the client can identify and discuss their emotions and feelings

Focus on their emotional experience (e.g. What emotions are you

experiencing now. What are your feelings?)


DEVELOP EMOTIONAL REGULATION

I am Mad – Sad - AnxiousI feel:• Accused • Guilty• Rejected • Unlovable• Powerless

“When I am out of WAC – I feel AGRUP” “However, I can regulate how I feel”

I am GladI feel:• Worthy• Acceptable• Capable

Help clients understand their emotions and feelings:

Fear/Shame Love/Empathy 1 2 3 4 5 6 7


THERAPEUTIC CONSIDERATIONSHelp them learn principles of emotional intelligence particularly how to

regulate their emotions.

Clients rarely know how to perceive the balance that is needed for recovery?

They seldom recognize how the 12 Steps integrate the key elements of

successful living.

Help them daily review their well-being.

Understand• Emotional self-regulation



NURTURING SELF-CARE

Clients hardly ever know how to perceive the balance needed for recovery

They seldom recognize how the 12 Steps integrate the key elements of

successful living

Help them daily review their well-being.


THERAPEUTIC CONSIDERATIONSA new approach to a greeting

Instead of; “Hi, how are you?”


THERAPEUTIC CONSIDERATIONSA new approach to a greeting

Instead of; “Hi, how are you?”

How goes your H E A R T? How is your Health? How are your Emotions? How is your Awareness? How are your Relationships? How is your Transcendent spirituality


HEALTHHow is your Health?

Sleep 7 to 8 hours Eat well Drink enough water Exercise regularly * Take care of health needs

Nurture your well-being Stop smoking * Take a supplement if needed Limit caffeine, sodas, & sugar

Which of these lower the risk for relapse?Which of these are you modeling for your clients?


EMOTIONSHow are your Emotions?

Recognize emotions & feelings

Regulate & soothe yourself

Appreciate positive feelings

Practice appreciating

Understand yourself

Use empathy to understand others

Emotional mindfulness is prerequisite to emotional intelligence We cannot control emotions but we can regulate them & soothe ourselves


AWARENESSHow is your Awareness?

Know what you are focusing on

Use your mind to resolve shame

Work through guilt

Value the worth of others & self

Realize that you are becoming more

Worthy, Acceptable, and Capable

Cognitive awareness is central to reason, logic, and effective actionThe ability to focus our mind changes our brain


RELATIONSHIPSHow are your Relationships? Clean up your side of the street

(& only your side)

Work through resentments

Practice forgiveness

Support the “Five Positives to One

Negative Interactions”

Sit as an adult not as a parent or

child

Know your family constellationsAlmost every person with an addiction as been the ‘victim’ of othersContinuing to blame is almost a sure sign of relapse – How come?


TRANSCENDENT SPIRITUALITYHow is your Transcendent Spirituality?

Find the joy in enjoyment and the

heart of courage in encouragement

Become open to ‘Coincidences’

How many of your clients have ‘religion problems’Many have not understood their spiritual experiences

(e.g. nature, caring, connection, wonder, etc.)

Develop your own sense of the

spiritual

Tap into the energy of your higher

power


SELF-CARE

The Self-care Imperative for RecoveryRecovery is not a simplistic formula

However, there are factors that greatly decrease risk factors

Most clients do not understand these concepts on first hearing

Seeking a balance in

health, emotions, awareness, relationships, and spirituality

is an ongoing, life-long journey

Factoids


What is the new pain med that will hit the streets next month?

Additional Job Security


What is the new pain med that will hit the streets next month? FDA approved in record time FDA advisory panel voted 11 to 2 against approval Alleviates chronic pain Better than Hydrocodone 5 – 10 mg



What is the new pain med that will hit the streets next month? FDA approved in record time FDA advisory panel voted 11 to 2 against approval Alleviates chronic pain Better than Hydrocodone 5 – 10 mg

Here comes Zohydro ER 50 mg



LIMITATIONS

“Because of the risks of addiction, abuse, and misuse with opioids,

even at recommended doses, and because of the greater risks of

overdose and death with extended-release opioid formulations, reserve

Zohydro ER for use in patients for whom alternative treatment options

are ineffective, not tolerated, or would be otherwise inadequate”


COUNTER POINT

We need effective pain medications

Physicians must assess for risks1. Exposure

2. Vulnerability of the individual

3. Current situation of the individual

There usually are options for those at risk of dependency

Factoids


Best predictor of successful therapy outcomes?

Considerations


Best predictor of successful therapy outcomes?

Counselors who ask their clients how they can be more effective.

Considerations

ConnectIsolation is the common thread in substance or behavioral addictions


PROBLEMATIC RELATIONSHIPS

They have poor relational conceptualizations

Expectations are high & acceptance is low

There is little ‘friendship’ in their relationships


THE POWER OF FRIENDSHIP

When individuals rediscover how to be friends:

Relationships start to heal & then flourish

The pieces fit

How does this happen?


Every friendship is composed of two separate relationships.

For example;

I have a relationship with Mark, my colleague at work

But Mark has a different perspective about his relationship with me

THERAPEUTIC CONSIDERATIONS


RECALL A CLOSE FRIENDExamples, a grandparent, a favorite friend growing up, a current BFF,

anyone you felt very close to (but not your spouse)

Think about how well you related to this friend

Then estimate how well they related to you

There are five qualities of interactions which summarize the closeness &

the effectiveness of the relationship between any two people. They are:


G R E A T FRIENDSHIPSAsk: Am I really . . .

• Genuine? Do I demonstrate that I am genuine by being honest, sincere, open, truth full, & transparent so

that others can be at ease with me?

• Respectful? Do I respect the ability of every adult to make their own choices even when I disagree? Do I

allow them to be responsible for the results of their decisions?

• Empathetic? Do I express through empathy that I care enough to listen, understand, and want the best for

the other person? Do I understand what others are saying, their feelings, their fears & their caring love?

• Accepting? Do I fully accept the other person as they are. Even when I disagree with them, can I express

my thoughts without ‘constructive criticism’ or imposing my values and expectations on them?

• Trustful? Do I believe in the basic good-hearted nature of the other person by acknowledging the best

about them? Am I trustful of their intentions?


AM I GENUINE?Do I demonstrate that I am genuine by being honest, sincere, open, truth

full, & transparent so that others can be at ease with me?

‘Are you honest, truthful, and open with your friend?’

‘Is it easy to be sincerely yourself?’

‘How do you encourage your friend to be comfortable with you?’

‘Does this work for both you and your friend?’


AM I RESPECTFUL?Do I respect the ability of every adult to make their own choices even when I

disagree? Do I allow them to be responsible for the results of their decisions?

‘Do you consent that your friend has the right to make their own decisions, even

when you differ with them?’

‘Does your friend allow you to do the same?’

‘Does this work for both of you?’


AM I EMPATHETIC?Do I express through empathy that I care enough to listen, understand, and want

the best for the other person? Do I understand what they are saying, their

feelings, their fears & their caring love?

‘Do you really try to understand your friend?’

‘Is it important for you to work ‘as a team’ and to be concerned about each

other’s best interests?’

‘Do both of you strive to understand the others perspectives and feelings?’


AM I ACCEPTING?Do I fully accept the other person as they are. Even when I disagree

with them, can I express my thoughts without ‘constructive criticism’ or

imposing my values and expectations on them?

‘Do you accept your friend, the good and not so good?’

‘Do you almost always refrain from criticizing them?’

‘Do you refrain from requiring your friend to meet your expectations?’

‘Are both you and your friend accepting of each other without feeling

submissive or compliant?’


AM I TRUSTFUL?

Do I believe in the basic good-hearted nature of the other person by

acknowledging the best about them? Am I trustful of their intentions?

‘Do you consistently see your friend as ‘well-intentioned?’

‘Generally, do you assume the best about your friend?’

‘Are you both trustful that each of you are good-hearted?’


If you are almost always . . .

Genuine Respectful Empathetic Accepting Trustful

Your relationship with your friend might look something like the

following slide:

G R E A T FRIENDSHIPS


MEASURING G R E A T:

GENUINE RESPECTFUL EMPATHETIC ACCEPTING TRUSTFUL

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If your friend is almost always . . .

Genuine Respectful Empathetic Accepting Trustful

You can estimate that your friend’s relationship with you might look

like the following slide:

G R E A T FRIENDSHIPS


G R E A T RELATIONSHIPS


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G R E A T RELATIONSHIPS


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How would you assess your relationships (e.g. family, clients, etc)?


CREATING ‘G R E A T’Focus on ‘what works’ and ‘what doesn’t work’

Ask yourself to do more of ‘what works’

Do G R E A T experiments

Observe how you feel, think, & act

Observe the results

Report how it works

As we model a G R E A T friendships we grow in our abilities


YOUR FRIEND

Empathetic

Accepting

TrustfulGenuine

Respectful

G R E A T FRIENDS

YOU

Empathetic

Accepting

TrustfulGenuine

Respectful


THE POWER OF FORGIVENESSResolving the imbedded resentment of trauma & chronic distress

Forgiving is not: Forgetting Excusing Trusting Continuing relationship


THE POWER OF FORGIVENESSResolving the imbedded resentment of trauma & chronic distress

Forgiving is not: Forgetting Excusing Trusting Continuing relationship

Forgiving lets go of the need for another to suffer for my sake

Resolved resentment alleviates triggers & frees the forgiver


BUILD GREAT CONNECTIONSOvercoming addiction’s isolation

Work through passed relationships concernsFamily conflicts

Prior injurious relationships

The impact of the addiction on loved ones Build functional, fun relationships – 12 steps, friends, etc. Learn how to trust & rely on others Develop a “Cone of Support” – Self, Reliable Others, H P


We all want to be heard, understood, and accepted

When we practice hearing, understanding, & accepting others – we become more

Worthy

Acceptable

Capable

THE POWER OF CONNECTION

Factoids


Testosterone levels decrease with opioid use

Considerations



Consider testosterone hormone replacement therapy after three months of abstinence & not feeling normal

Considerations




ADD, ADHD can interfere with recovery

Considerations




ADD, ADHD can interfere with recovery

Consider Strattera (non-stimulant) medication

Considerations

ImagineerHelping those recovering to visualize and create meaningful, enjoyable lives


THE CRUCIAL QUESTION

“What are you going to do with the rest of your life?”

In addiction, creativity is focused on obtaining, using, & hiding the use of substances

There is little or no effort concentrating on obtaining enjoyment, meaning, or fulfillment

Those caught up in dependence fear the responsibility & opportunity to create their own life

In recovery, sobriety is never enough – it is fundamental but each person has to envision their life as satisfying & worthwhile


WALT DISNEY’S DILEMMA: Many of his staff were talented artists – he valued their creative

imaginations

But in developing Disneyland, he needed engineers to turn

imagination into reality

How could he combine the best of both?

Today’s most coveted work title for Disney employees


WALT DISNEY’S DILEMMA: Many of his staff were talented artists – he valued their creative

imaginations

But in developing Disneyland, he needed engineers to turn

imagination into reality

How could he combine the best of both?

Today’s most coveted work title for Disney employees

Imagineer


THERAPEUTIC CONSIDERATIONS

Engage the client in identifying their values: Many do not know their values

Many are conflicted between their held values & behaviors

Listing values by each person in a group is value provoking

Individuals can track their own reliability

Self-trust is dependent upon consistency at 97%


WHAT R U 4?

Identify aspirations (We are what we desire to be) Show how unproductive it is to focus on what they do not want

Help them focus on the desires they want in their life Teach them to use the power of visualization

Demonstrate how to daily engineer the creation of their desires

Create a wheel of good fortune

Factoids


If an individual smokes within one hour of wakening there

is a significantly greater risk of addiction

What does this mean for those who are in recovery?

Consider

Bringing it Home


THE FOUR PARADIGMS OF RECOVERY: 1.Integrate withTwelve Steps programs

2.Address the underlying distress sources of addictions

3. Help clients build their life’s path & their own program of recovery

4. Are based on holistic health principles utilizing individual skill development

5. Positive reinforcement is a natural effect of using these skills

6. Clients learn how to put into practice these skills & achieve better outcomes

7. It is imperative that we also attend to taking care of ourselves by practicing these skills with our clients, those whom we work with, as well as our family and friends


Those in long-term recovery meet the following criteria:1. Believe They exhibit positive self-beliefs

2. Understand They show an internal sense of

Emotional self-regulation

Nurturing self-care

3. Connect They achieve effective interpersonal relationships

4. Imagineer They realize their own purpose and meaning

Four Paradigms of Recovery

Questions?

Four Paradigms of Recovery A Criterion Counseling Model for Successfully Overcoming Addiction

H. Gray Otis, PhD, CMHC, DCMHS-TClinical Director, The Phoenix Recovery Center

[email protected]

www.ThePhoenixRC.com

801-885-8585

Four Paradigms of Recovery A Criterion Counseling Model for Successfully Overcoming Addiction H....

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