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Dr Andrew Derry Clinical Psychologist

© 2005

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Table of Contents: INTRODUCTION: USE OF THE MANUAL ................................................................... 6

The Drug and Alcohol Group Programme........................................................................................... 6 Use of the Manual ............................................................................................................................... 6 Presentation Style ............................................................................................................................... 8 Presentation Traps .............................................................................................................................. 9 Terminology....................................................................................................................................... 10 Philosophy of the Programme ........................................................................................................... 10 Facilitators ......................................................................................................................................... 10 Participants........................................................................................................................................ 11 Additional Sessions ........................................................................................................................... 11 Evaluation.......................................................................................................................................... 11

ASSESSMENT ............................................................................................................. 12

RELAPSE INTERVIEW ................................................................................................ 14

MODULE 1: MOTIVATION TO CHANGE................................................................... 15

SESSION 1: Exploring Expectations .................................................................................... 15 Exercise 1: Why have participants joined the group?........................................................................ 15 Exercise 2: Setting ground rules ....................................................................................................... 15 Exercise 3: Goals .............................................................................................................................. 16 Assignment: Aims and objectives...................................................................................................... 17

SESSION 2: Why do I use drugs or alcohol? ................................................................... 18 Exercise 1: Pros and Cons of Drug or Alcohol Use........................................................................... 18 Exercise 2: Thinking about advantages and discounting the disadvantages? .................................. 19 Exercise 3: Looking for alternatives .................................................................................................. 20 Assignment: What are the alternatives to drugs and alcohol ............................................................ 20

SESSION 3: Motivation to Change.................................................................................... 22 Exercise 1: Ever tried to change anything?....................................................................................... 22 Exercise 2: What do you want to change? ........................................................................................ 23 Exercise 3: Importance and confidence to change ........................................................................... 23 Exercise 4: Barriers to Change ......................................................................................................... 24 Assignment: Myths about substance use..........................................................................................24

SESSION 4: Overcoming Barriers to Change .................................................................. 25 Exercise 1: Myths as brainwashing ................................................................................................... 25 Exercise 2: What are your myths and how to challenge them?......................................................... 26 Exercise 4: Undoing the brainwash................................................................................................... 26 Assignment: Substance use and behaviour ...................................................................................... 27

MODULE 2: UNDERSTANDING MY SUBSTANCE USE .......................................... 28

SESSION 5: What do drugs and alcohol do to me? ........................................................ 28 Exercise 1: How do drugs or alcohol affect me? ............................................................................... 28 Exercise 2: Why do we enjoy using drugs and alcohol? ................................................................... 29 Exercise 3: What is addiction? .......................................................................................................... 30 Assignment: Read Information on drugs and alcohol....................................................................... 30

SESSION 6: How do drugs and alcohol effect my mood and behaviour? ......................... 39 Review Assignment: Quiz on substance use. ................................................................................... 40 Exercise 1: How do drugs or alcohol affect my behaviour?............................................................... 41 Exercise 2: How do drugs or alcohol affect my mood? ..................................................................... 42

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Exercise 3: How can drugs and alcohol effect other people?........................................................... 43 Assignment: Something regretted? .................................................................................................. 44

SESSION 7: How do drugs and alcohol affect offending and decision making?.......... 46 Exercise 1: Types of offences ........................................................................................................... 46 Exercise 2: How is offending linked to substance use?..................................................................... 47 Exercise 3: How is offending linked to substance use?..................................................................... 47 Assignment: Vulnerability and protective factors.............................................................................. 48

SESSION 8: Do Drugs and Alcohol affect my Mental Health? ........................................ 49 Exercise 1: Do drugs or alcohol affect your mental health? .............................................................. 49 Exercise 2: Do drugs or alcohol affect mental health and re-admission to hospital? ........................ 50 Exercise 3: How do drugs and alcohol affect medication?............................................................... 51 Exercise 4: Do drugs and alcohol increase vulnerability to mental illness? ...................................... 51 Assignment: How do drugs and alcohol affect your mental health?................................................. 52

SESSION 9: How do drugs and alcohol cause mental health relapse? ......................... 54 Exercise 1: What are your early warning signs? ............................................................................... 54 Exercise 2: Drugs and alcohol as Self-medication? .......................................................................... 55 Exercise 3: The vicious circle of drugs alcohol and mental health problems? .................................. 56 Exercise 4: How to get out of the vicious circle? .............................................................................. 56 Assignment: High Risk Situations? .................................................................................................. 57

MODULE 3: RELAPSE PREVENTION ...................................................................... 58

SESSION 10: What is Relapse Prevention? ........................................................................ 58 Exercise 1: What does relapse or relapse prevention mean?.......................................................... 58 Exercise 2: Review Homework - Describe a relapse situation? ....................................................... 59 Exercise 3: What are your High Risk situations?.............................................................................. 59 Exercise 4: What are the ways of coping with high-risk situations? ................................................. 60 Assignment: Thoughts that justify substance use ............................................................................ 61

SESSION 11: How can my thoughts make me relapse?.................................................... 62 Exercise 1: How can our thoughts put us at high-risk of using drugs or alcohol? ............................. 62 Exercise 2: Challenging our automatic thoughts ............................................................................... 63 Exercise 3: Role-Play: Giving rational responses? ........................................................................... 64 Assignment: Thought records ........................................................................................................... 64

SESSION 12: How can Unconscious Actions make me relapse?..................................... 65 Exercise 1: What are Unconscious Actions?..................................................................................... 65 Exercise 3: What are my Unconscious Decisions? ........................................................................... 66 Exercise 4: Coping with Unconscious Actions? ................................................................................ 67 Exercise 4: The Problem with Impulsiveness.................................................................................... 67 Exercise 5: Coping with Impulsivity ................................................................................................... 68 Assignment: What to do in high-risk situations?................................................................................ 68

SESSION 13: Relapse Prevention Planning........................................................................ 69 Exercise 1: Why make a plan?.......................................................................................................... 69 Exercise 2: What actions can be taken as part of this plan?............................................................. 69 Exercise 5: Role Play Risk Planning ................................................................................................. 70 Exercise 3: What should I do at different levels of risk?.................................................................... 70 Exercise 5: Skills Planning ................................................................................................................ 71 Assignment: Meet with primary nurse / care co-ordinator. ................................................................ 71

MODULE 4: DEVELOPING SKILLS .......................................................................... 72

SESSION 14: Coping with Temptation and Cravings........................................................ 72 Exercise 1: What are temptations or cravings?................................................................................. 72

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Exercise 2: Developing skills for dealing with temptations and cravings........................................... 73 Exercise 3: What are my temptations and cravings .......................................................................... 73 Exercise 4: Heart Rate Monitoring .................................................................................................... 74 Exercise 6: Relaxation Skills ............................................................................................................. 74 Assignment: Diary of Coping with Temptation................................................................................... 75

SESSION 15: Coping with Thoughts.................................................................................... 76 Exercise 1: How can automatic thoughts lead us to a High Risk Situation ....................................... 76 Exercise 2: Self-statements Skill ....................................................................................................... 77 Exercise 3: Thought Distraction Skill ................................................................................................. 77 Exercise 4: Thought Replacement Skill............................................................................................. 78 Exercise 5: Mindfulness Skill ............................................................................................................. 78 Assignment: Diary of Coping with Thoughts...................................................................................... 79

SESSION 16: Coping with Moods and Emotions................................................................ 80 Exercise 1: Recognising emotional states......................................................................................... 80 Exercise 2: Which moods put us at high-risk of using drugs and alcohol?........................................ 81 Exercise 3: Not putting ourselves in situations that cause high-risk moods?.................................... 82 Exercise 4: What can we do about our emotions? ............................................................................ 82 Assignment: Diary of coping with moods .......................................................................................... 83

SESSION 17: Coping with Symptoms and Side Effects..................................................... 89 Exercise 1: How do we Recognise Symptoms?................................................................................ 90 Exercise 2: Do drugs and alcohol help to manage symptoms?......................................................... 90 Exercise 3: How can medication help us with symptoms of mental illness? ..................................... 91 Exercise 4: Skills for coping with symptoms...................................................................................... 91 Exercise 5: What are side effects and how can we cope with them................................................. 93 Assignment: Diary of Coping with Symptoms and Side Effects ........................................................ 93

SESSION 18: Coping with Anger and Arguments .............................................................. 97 Exercise 1: How does anger affect us?............................................................................................. 97 Exercise 2: What makes us angry?................................................................................................... 98 Exercise 3: What do we think in angry situations? ............................................................................ 98 Exercise 4: Assertiveness skills ........................................................................................................ 99 Exercise 5: Role-Play Assertiveness skills ...................................................................................... 100 Assignment: Diary of Assertions Skills ............................................................................................ 100

SESSION 19: Coping with Persuasion and Saying “No” ................................................. 102 Exercise 1: How do other people influence us? .............................................................................. 102 Exercise 2: What are the ways people influence our use of drugs or alcohol? ............................... 104 Exercise 3: How do we cope with social situations? ....................................................................... 104 Exercise 4: Broken Record Skill ...................................................................................................... 105 Assignment: Diary of Coping with Persuasion ................................................................................ 106

SESSION 20: Getting Support ............................................................................................ 107 Exercise 1: How are some people or social situations not helpful?................................................. 107 Exercise 2: How can some people or social situations be helpful? ................................................. 108 Exercise 3: Drawing a Social Network Map .................................................................................... 109 Exercise 4: How to recruit social support? ...................................................................................... 109 Exercise 5: How to recruit professional support? ............................................................................ 111 Assignment: Getting Professional Support...................................................................................... 111

SESSION 21: Quitting after a slip....................................................................................... 112 Exercise 1: Introduction to relapse prevention? .............................................................................. 112 Exercise 2: What happens after a slip?........................................................................................... 112 Exercise 3: Thoughts and decisions................................................................................................ 113 Exercise 4: When is a good time to stop? .......................................................................................114 Exercise 5: Fixing Limits.................................................................................................................. 115

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Assignment: Fixing Limits Practice................................................................................................. 115

SESSION 22: Skills Practice ............................................................................................... 120 Exercise 1: Skills Presentation ........................................................................................................ 120 Exercise 2: Practising Skills ............................................................................................................ 121 Assignment: Which Skill? ................................................................................................................ 121

SESSION 23: Relapse Prevention Planning Revisited ..................................................... 133 Exercise 1: Why are our high-risk situations high-risk?................................................................... 133 Exercise 2: Relapse prevention planning ........................................................................................ 134 Exercise 3: What skills can we use to cope with high-risk situations? ............................................ 135 Exercise 4: Skills role-play .............................................................................................................. 135 Assignment: Review of the programme .......................................................................................... 136

SESSION 24: Changing Lifestyles and Moving On…....................................................... 137 Exercise 1: Changing Lifestyles ...................................................................................................... 137 Exercise 2: Making the Change ...................................................................................................... 138 Exercise 3: Why look after yourself? ............................................................................................... 138 Exercise 4: Moving on ..................................................................................................................... 139 Exercise 5: Feedback...................................................................................................................... 139 Assignment: Meet with Primary Nurse or Care Co-ordinator .......................................................... 139

INTRODUCTION: USE OF THE MANUAL The Drug and Alcohol Group Programme

This programme has designed for treating offenders with substance use problems and severe mental illness. It differs from other programmes in that it is aimed at in-patients within medium secure and low secure mental health units and rehabilitation hostels. This programme is different in that it examines the close relationship between substance use, mental health problems and offending. This programme assumes that whilst drugs and alcohol are available in forensic settings, that individual’s are largely remaining abstinent or minimising their substance use. This is not to say that they are necessarily at the ‘maintenance stage’ of relapse prevention, but that they are not exposed to the easily available drugs or alcohol and the stressors associated with drug and alcohol use in community settings. This group is therefore aimed at individuals in the contemplation and active treatment stages of relapse prevention. The first module aims to increase participant’s desire to change their pattern of substance use prior to admission. The second module aims to provide information about the links between substance use, mental illness and antisocial or offending behaviour. The third module introduces the concept of relapse prevention and identifies common threats to maintaining abstinence from drugs and alcohol. The fourth module introduces skills that will help the individual maintain abstinence following discharge. Use of the Manual

The Substance Use Programme for Mentally Disordered Offenders was designed for use with mentally disordered offenders who have had an identified problematic use of substances. It was designed predominantly as a manual for group interventions although it is possible to adapt this intervention for use in one-to-one sessions. Session Format: Each session is presented in a way that is simple to follow and predictable for both the facilitator and the participants. For each session:

1. The main topic for that session is introduced through a stimulus question or discussion. This can be done through the use of an example or a ‘thought-provoking’ question. The introductory notes should not be read verbatim as these are written in the participants’ handbook.

2. The assignments are then reviewed, which help participants to think about what was discussed in the previous session, and establish their motivation within the group. Assignments are also designed as a primer for the next session so they may form part of the introduction to the session.

3. The session is then broken up into individual exercises. These exercises are designed to vary so that the sessions do not become monotonous. There is an explanation at the beginning of each exercise to guide the facilitators in that exercise. Symbols are used as a short-hand way of identifying the nature of each exercise and what materials are used

4. Sessions are finished by discussing and if necessary practising the assignment between sessions. In some exercises there is a learning point that should be elicited from the participants, although it may need to be summarised by the facilitator.

Session Length: Sessions are planned to last for two hours with a 10-minute break in the middle. However, some participants are not able to sustain this level of attention and the two parts of each session can be broken up into morning and afternoon or different days of the week. Sessions are ideally run at least twice weekly, although this should be at least weekly in order to maintain a focus on this issue.

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Session Objectives: At the beginning of each session there are highlighted a number of session objectives to orientate the facilitators and introduce the session. These are the issues that are to be discussed and covered within the session. Key Issues: For each session, the some key issues are identified. This can point out some of the background information to each session or some of the pitfalls in running that session. They are designed to enhance the facilitators understanding of the objectives in running the session. Assignments Assignments are set at the end of each session as a means of assessing the individual’s motivation to change their drug and alcohol, reinforcing leaning during the group sessions, and preparing for the next weeks sessions. Whilst the group runs for only a few hours each week, clients will be struggling with this issue throughout the week. Assignments reinforce the idea that changing behaviours take place outside of the groups as well. Manual Format

Each module, session and exercise is introduced to the facilitators with a paragraph about that section. The writing in italics is for the facilitators’ information and does not need to be read out. It should give the rational of the exercise so that it can be interpreted. Symbols:

Group discussion: This can be an open discussion around a topic started with a stimulus question, or there can be a number of stimulus questions or suggestions to orientate the discussion.

Flipchart exercise: Flipchart exercises can summarise information in front of the group.

Information on flipcharts should be kept to a minimum and the use of symbolic language should be encouraged. These can also be copied into workbooks that run parallel with the discussions.

OHP presentation: These are listed in the manual in each session and in certain cases are also

in the patient’s handbook for their own reference.

Workbook Exercise: Some exercises are workbook based in order to keep a record of the information for the individual’s future use and as assignments.

Role Play/Group exercise: These type of exercises involve participants acting out parts which

may represent some aspect of their offending and

Materials: This lists the types of materials you will need during the sessions as well as the flipchart and OHP as standard for each session.

Photocopy: Pages may be photocopied for distribution

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Presentation Style

This Substance Use Programme for Mentally Disordered Offenders employs cognitive-behavioural therapy as the basis for intervention. The intervention style is that of collaborative and experiential learning. In this, it is essential that a collaborative understanding of the individual’s substance use is developing throughout the programme. It is essential that a non-judgemental approach is employed, even if the client’s acknowledgement of their substance use is significantly different from the historical evidence available. This non-judgemental approach aims to develop a trusting therapeutic relationship within which the difficulties of substance use can be explored. This approach requires empathy, warmth and unconditional positive regard for the person (Rodgers, 1991)1. In this, the therapeutic stance is neutral regardless of the facilitator’s beliefs about the effects of using drugs and alcohol. A more pragmatic approach is necessary, in which substance use is placed in context of the individual’s desired outcomes (goals) and personal objectives. This programme aims to use “Positive Psychology” (Padesky, 2003)2 which focuses on positive traits and builds positive qualities of individuals. Each of the following methods can be employed during all of the exercises of this substance use programme although they become particularly important during discussion sessions. Open Questions Each of the exercises are introduced through the use of questions and active learning, rather than didactic teaching by reading out the exercise or lecturing. Each of the exercises should be introduced with interesting stimulus questions or introductory statements for discussion. Reinforcing change and pro-social attitudes and beliefs Throughout the programme, body language can be used to positively reinforce participant’s beliefs that they can change their substance use and pro-social attitudes and beliefs whilst ignoring offending and antisocial attitudes. This can be done through reinforcing positive change statements by approaching the person, repeating or congratulating their statement, inviting others to think about the pro-social or pro-change statement. It is important not to reinforce antisocial, pro-substance use statements through moving away from the person, moving on to the next person without responding to the statement rather than focusing on negative statements. Language Constructive Language should be used throughout this Substance Use Programme. This aims to shift the focus from problems and difficulties to emphasise potential strengths, skills and coping abilities. (E.g. How would you like things to be? What would you like to do instead? Can you imagine things being different?). This language is likely to become more constructive during the course of the programme as it shifts from Understanding Substance Use module in which there is a greater focus on problems to the Relapse Prevention and Skills Development modules. Guided Discovery The use of guided discovery in the substance use programme aims to uncover information about the clients drug and alcohol behaviours outside of the individual’s awareness (Padesky, 1995)3. It does this through listening to accounts of substance use and reflecting these issues back to individuals, and using discussion questions that question beliefs underlying and maintaining substance use. Socratic Questioning Socratic Questioning is the use of reflective questions to encourage participants on this programme to develop their own understanding of their drug or alcohol use without feeling lectured on the issue. This technique uses a series of questions or reflections to explore existing assumptions about substance abuse. It does this not through disagreeing with the participant about his or her views, but by following them to their logical conclusion. 1 Rogers, C.R. (1991). Client-Centred Therapy. London: Constable. 2 Padesky, C. A. (2003) Conference: Cognitive Therapy Unplugged. 3 Padesky, C. A., & Greenberg, D. (1995) Clinician’s Guide to Mind Over Mood. New York: Guilford Press.

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The Socratic dialogue involves four stages:

1. Asking informational questions a. Can you give me an example? b. How is this a problem for you? c. What has happened in the past? d. How would you describe this to a friend?

2. Listening: a. Being empathic. b. Noting images, metaphors, and ideas c. Being aware of omitted information or alternatives.

3. Summarising: a. Stating the initial belief in a concise summary. b. Verbally bullet pointing some of the assumptions made

4. Asking analytical / synthesising questions: a. Asking the group what they make of these assumptions/beliefs (e.g. “Do other people feel

that cannabis can help you relax?”) b. Looking at conflicts in the assumptions (e.g. “How does your feeling that using cannabis

helps you relax with your earlier feelings that it can make you anxious?”) c. Looking for conclusions (e.g. “Are there other ways of relaxing without the risk of feeling

anxious?”) d. Take another perspective (e.g. “What do you think a friend or relative would recommend

to you to relax?”) Motivational Interviewing Miller and Rollnick (2002)4 define motivational interviewing as a client centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. This approach:

1. Selectively reinforces the desire for change and the individual’s beliefs that they can achieve their change goals. (e.g. “It sounds as though it is really important for you to stop using alcohol as it could lead you to being arrested or returning to hospital.”)

2. Addressing the resistance to change (e.g. “It sounds as though you would feel very isolated if you didn’t go to the pub in the evening”)

3. It uses the individual’s intrinsic motivation to change (e.g. better relationship with partner) rather than the use of external reinforcers or disincentives including sanctions or punishment (e.g. financial gain, better health prison, or hospitalisation)

Presentation Traps

Presentation traps are described by Miller and Rollnick (2002). These are the patterns of behaviour the facilitator can fall into despite the best of intentions but can inhibit the change process. These include:

1. The Question and Answer Trap: persistently asking questions in order to elicit answers, and thereby the facilitator controls the session.

2. The Trap of Taking Sides: When individuals are ambivalent about their use of substances, the facilitator takes the side of the “problem” rather than the “no-problem” the facilitator is taking responsibility for changing the problem.

4 Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing: Preparing people for Change. Second edition. New York: Guildford Press. Pp. 55-63.

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3. The Expert Trap: This happens when the facilitator shifts into problem-solving mode and attempt to try and ‘fix’ the problem, by giving advice and recommendations. It tends to shift the participant into the passive role rather than developing their own expertise around this issue.

4. The Labelling Trap: This occurs when facilitators attempt to categorise problems into diagnostic labels, (e.g. drug users, alcoholics). This can increase resistance within participants struggling with the idea of having any substance use problem. Labelling can also assert some power over participants increasing their passivity about a problem.

5. The Premature-Focus Trap: When a facilitator attempts to point out a participant’s drug or alcohol problem, or identify solutions prior to a problem being recognised, then they are likely to encounter resistance. This often occurs when the facilitator attempts to draw attention to issues

6. The Blaming Trap: In the early stages of change a participant may be concerned about their own responsibility or role in the problem. This may lead to some defensiveness or concern about blaming. This in turn can lead the facilitator to point out the participants role in their own substance use. This can lead to deadlock in the change process.

Terminology

The terminology used throughout this manual is designed to maintain jargon and mental health language to a minimum. It also attempts to maintain some consistency in the language used in order to help individuals remember the concepts being used. 1. Where possible the term “drug or alcohol use” should be used rather than the more technical term

substance use. The term or should be used in place of and as individual may want to change their use of one group but do not identify themselves as having difficulties with another group of substances.

2. “Substance use” is used in place of “Substance Misuse” in recognition of individual’s use of drugs as

a form of medication to help manage emotions, personal and interpersonal problems. 3. The term “individuals” or “participants” is used rather than patients as it is recognised that this

manual may be extended to non in-patient populations. 4. The terms “thoughts” or “beliefs” should be used rather than cognitions in order to simplify language

and make the programme more ‘real’.

Philosophy of the Programme

Harm-Reduction vs. Total Abstinence The attitudes of individuals and their stated aims and goals in relation to using drugs and alcohol will vary at different stages throughout the programme. The programme itself does not make recommendations about the level of use to participants. However, the programme is orientated towards abstinence from drugs and alcohol and the skills developed in this programme predominantly focus on “staying free” from drugs or alcohol. Towards the end of the programme, there are harm-reduction exercises for individuals that have either decided that they would like to limit their use of substances to levels that do not impair their personal functioning to such a degree. Facilitators

Ideally, each programme should have two facilitators. If one of the facilitators is leading the group or training the second facilitator, the lead facilitator should have experience in both Cognitive Behavioural Therapy and presenting group programmes.

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Participants

This programme was designed for mentally disordered offenders with identified histories of substance use. Ideally this programme was aimed at:

1. Participants with a history of drug or alcohol use or those who currently use.

2. Participants with a history of mental illness.

3. Participants with an offending history.

4. Participants aged of 16 and 70.

This programme was not designed specifically for groups with particular problems, although groups with relatively homogenous use of drugs (e.g. all used crack and cannabis) may want to change some of the language in the manual. Nor was this programme designed only for individuals who are currently using drugs or have active symptoms of mental illness.

Additional Sessions

Pre-and Post-programme Interviews The pre-programme interview allows the facilitators and other professionals gain an understanding of level of substance use problems and the participant’s motivation to change these problems. This also gives the opportunity to complete the measures evaluating the programme. Meeting with the Primary Nurses or Care Co-ordinator There are planned meeting at the middle and end of the programme. The purpose of these meetings is to congratulate participants for their successful completion of the programme so far. These meetings are also an opportunity for the participant to describe what they have gained so far from the programme and re-iterate their goals and objectives for their substance use. Relapse Interviews It is possible that there are likely to be situations where the participant relapses during the course of the programme. This may have been identified by the participant or through the use of drug screening tests. It is important to use these situations to gain an understanding of the participant’s difficulties in changing their substance use. Evaluation

It is important to evaluate the effectiveness of any treatment programme. A pack of pre- and post-programme questionnaires and semi-structured interviews accompanies this programme manual and participant handbook.

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ASSESSMENT INTRODUCTION

Assessment Questions:

1. When did you first start using drugs or alcohol and how has this changed since?

This question aims to understand the chronicity of drug and alcohol use and how it has changed over time. It also serves as a lead in question to how this has interacted with life events such as hospitalisation, prison and family changes.

2. Do you currently use drugs or alcohol / when did you last use drugs or alcohol? This asks about current use and the reasons for stopping if they have not used for some time. 3. Develop a time line of substance use using different colours for each substance and significant

events:

Offending/Prison:

Hospitalisation:

Family events:

Other (e.g. trauma):

0%

20%

40%

60%

80%

100%

10 to 15 15 to 20 20 to 25 25 to 30 30 to 35 35 to 40 40 to 45 45 to 50 50 to 55

Assessment Objectives 1. Introduce the group facilitators before the group starts 2. Give an overview of the group 3. Build the teamwork between participant and primary nurse 4. Gain an understanding of why the individual uses drugs or alcohol 5. Assess their motivation to change substances 6. Assess the confidence in changing and start to explore attitudes to change 7. Develop an understanding of the family or peer substance use and any difficulties

that this may present to remaining abstinent from drugs or alcohol 8. Gain an understanding of any other interventions e.g. individual psychotherapy or

AA

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4. Have you ever tried to stop your use of drugs or alcohol? What would you like to change about

your previous use of drugs or alcohol? This assesses the individual’s motivation to change their use of substances and the key reasons that they would like to

change. It also explores whether the person feels that they are able to change their use and how this has worked out. 5. How has your drug or alcohol use related to your mental health in the past?

This should explore how substances have been used prior to mental health relapse, coping with symptoms or moods and thoughts.

6. Has your substance use ever led you to do something that you regret or get in trouble with the

law? This question explores the links between substance use and problem behaviour or crime. 7. How has your past drug and alcohol use affected your relationships in the past? Who is this a

problem for? Do your friends or family help you to stop or encourage you to use drugs or alcohol? This question aims to understand how drugs and alcohol have effected the social network including intimate and family

relationships or friendships, and how the social network effects the individual’s use of drugs or alcohol? 8. Have you ever received any help with stopping using drugs or alcohol in the past? This question asks about the type, duration and type of previous treatment and what was the outcome (advantages or

difficulties) in this treatment? 9. Which situations do you think would put you at risk of using drugs or alcohol? How would you

cope with these situations? This question aims to get an understanding of the person’s existing relapse prevention strategies and how effective

they are. 10. Have you ever been in any therapeutic groups before and how do you feel about joining this

group? How do you feel about talking about your drug and alcohol use? This question asks about the person’s anxieties about joining the group and identifies any anticipated problems.

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RELAPSE INTERVIEW INTRODUCTION

This relapse interview is to be undertaken when an individual either tests positive for drugs or alcohol, or they have reported that they have been using. This interview aims to identify the specific situations, moods, symptoms and thoughts that lead to using drugs or alcohol and how the person attempted to remain abstinent. This interview should not be used to gain information about the origin of the drugs or alcohol. Information from this interview should be incorporated into a personal care plan with a view to reducing relapse in the future. 1. What substances were taken? / Which drugs or alcohol did they test positive for? 2. Is the person recognising/reporting that they used drugs or alcohol? Yes No

3. What were the main factors in using drugs or alcohol?

SITUATION MOODS/SYMPTOMS THOUGHTS e.g. Being offered drugs e.g. feeling anxious and edgy e.g. I’ll use just this once

4. Did they attempt to abstain from drugs or alcohol? If so, how? 5. What skills did they use to try and manage the situation?

E.g. assertion skills, relaxation

6. What skills could be developed to help the person abstain in future?

Additional skills development should be linked to the main relapse factors e.g. being offered drugs -> saying “no” or other assertion skills.

7. What is the outcome and how does the care plan need to be changed?

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MODULE 1: MOTIVATION TO CHANGE SESSION 1: Exploring Expectations INTRODUCTION

Welcome the group and each member of the team should introduce their role, and what they prefer to be called. This should include all staff including observers. It should be explained that observation is necessary for staff training even though it may seem intrusive. Each participant should take it in turns to introduce themselves by the name they wish to be called in the group. Group facilitators should thank participants for their contribution and use each individual’s name at every opportunity. Encouragement should be given to pro-social comments. Exercise 1: Why have participants joined the group?

This brief exercise is designed to elicit from the group what their motivation for attending is and how they have come to be there. It is hoped that clients will be able to disclose any doubts they have about the group or how difficult or daunting they may find the change process.

I would like you to give me some reasons that you have come to the group. What would you like to get out of the group?

Do not challenge individual answers, only ask further questions regarding their motivation. Focus on positive responses and skip-over antisocial answers. Introduce the rational of the group: This group is not designed to tell you to stop using drugs or alcohol. It is designed to look at why you use drugs and alcohol and to develop skills that will enable you to make a choice as to whether you take drugs or alcohol. Use the analogy that in one pocket you have drugs and in the other you have some skills to cope with temptation. Describe the process of learning: We learn by doing, and many of the skills are learnt through exercises. This will include exercises in your handbooks, on the board role-play and most importantly games. Participants may not initially feel comfortable with taking part, particularly role-play. Emphasise the importance of having fun whilst learning. Exercise 2: Setting ground rules

Setting group rules enables participants to address their drug and alcohol use without worrying that they are going to be In order to learn with confidence, it is important to do this within an environment where we feel safe to talk about issues. It is therefore important to set some group rules.

Session Objectives 1. To introduce the course and facilitators.

2. Find out why participants are joining the group.

3. To develop a rapport between group members and facilitators.

4. To gain an understanding of the individual’s goals and objective and how drugs and alcohol fit into these.

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Ground Rules The facilitator should suggest a few rules and then elicit ideas from the group. If inappropriate rules are offered, then emphasise that the group is run by the group and that the rules are for the benefit of the group. State that these rules will be typed up and given to all participants in the next session. Suggested rules: 1. One person speaks at a time. 2. Attending the group on time 3. No interrupting 4. Don’t talk about other people’s private issues Other rules: These rules are not for discussion. They are for safety. 1. No smoking during the group other than the break. 2. No leaving the group during the session. 3. Punctual attendance. Exercise 3: Goals

There is an old saying: “I you don’t know where you are going, you won’t know when you

get there”. It is important to identify goals in order to know where we are going. Invite the group to describe aspects their ideal situation: Imagine you wake up and everything is the way that you want it to be. What would be your ideal situation? Leave the group to think about it during the break and give answers after the break Emphasis the importance of thinking, and how much fun it can be. Imagination is a fun way of thinking. BREAK Emphasise the importance of timekeeping.

Imagine you wake up and everything is the way that you want it to be. What would be your ideal situation?

Elicit ideal situations from individuals, encouraging pro-social responding. Facilitator summarises aspects of fantasy that can be applied to real situations. Summarise ideas in terms of normal aspirations:

Ideal Situations Goals e.g. driving a fast car -> being wealthy

sleeping with many people -> being attractive and popular getting stoned -> feeling good about ourselves

(Only write down pro-social aspects of the fantasy (being successful, having a family, good relationships)

What are your Goals?

Draw a picture of half a football field and write down personal goals in the goal area.

What do we have to get from here, in our current situation to there this ideal situation, here? Emphasise the need for personal change in order to achieve our personal goals. If only immediate gratification responses are offered (e.g. get out of here), then emphasise: “What do we need to change about ourselves to do that?”

What are your objectives?

Write down the objectives in the midfield area of the football pitch.

Use football as an analogy to explain the difference between Goals and Objectives: Objectives are the passing and setting up the goal, scoring the goal is achieving the objective.

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Is it always necessary to know your objectives?

What happens if you do not have objectives? When is it most important to know the objectives?

Do drugs and alcohol help in achieving your current objectives or future goals? On the football pitch, place a or next to each of the objectives or goals indicating whether they are likely to help achieve a goal or objective or not.

Assignment: Aims and objectives

What is your personal ‘ideal situation’ in life or your eventual goals?

What are your short-term objectives to reach your eventual goal? What role do drugs or alcohol play in your objectives and final goals in life?

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SESSION 2: Why do I use drugs or alcohol? INTRODUCTION

This session aims to gain an understanding of people’s reasons for using drugs and alcohol. It looks at people’s beliefs about the advantages or disadvantages of using drugs or alcohol. This can inform the individual’s treatment needs through increasing the advantages of not using and increasing the disadvantages of using drugs and alcohol. Key Issues: • The purpose of this session is to increase our understanding of a problem and to normalise the

experience of having problems. • In order to do something about a problem, how do we know if it is a problem and what is

problematic about it? • Do not assume that drug or excess alcohol use is necessarily a problem. Acknowledge that there

are positives and negatives in using drugs and alcohol, but that there are always aspects of drug and alcohol use that can be problematic.

Review Assignment: Aims and Objectives

This review is designed to remind individuals about the previous session’s topics and introduce the present session. There is no way of enforcing that assignments are completed, but this will be encouraged by reinforcing individuals completion of assignments through attention and praise and asking those who have not completed the assignment to complete it during the break. Getting into the habit of checking assignments will encourage individuals to think about their substance use between sessions. However, try not to spend more than 15 minutes reviewing previous sessions.

What were the questions we were going to think about from last time? Try and elicit the assignment questions to establish who has been thinking about this issue since last week.

What role does drug and alcohol play in your ideal situation? What are your short-term objectives to reach your eventual goal? Exercise 1: Pros and Cons of Drug or Alcohol Use

This exercise aims to look at individual’s personal reasons for using drugs and alcohol. It does this by looking at the advantages and disadvantages they believe exist in using or not using drugs or alcohol. There are a number of overlaps between the advantages of using and the disadvantages of not using but these help to elicit the reasons for ongoing use. It is important that facilitators help participants to think about areas that participants have not previously considered e.g. relationships, work coping with moods or sleep

In order to understand why we really use drugs and alcohol, we must understand the reasons that we give ourselves for using.

Session Objectives 1. To explore what participants think are the advantages or disadvantages of using

drugs and alcohol. 2. To think about whether we are using all the information to make choices about

our substance use or whether we are stopping ourselves from thinking about it. 3. To think about the alternatives to drugs and alcohol that may replace the need for

using substances.

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The Pros and Cons of drug or alcohol use? In the handbook, write down advantages and disadvantages of using drugs or alcohol. It is important that participants think about the times that they have used drugs or alcohol in the past and think why they were doing it then. E.g. using drugs on your own may be a way of coping with loneliness.

Using substances Not using substances

Advantages

feeling stoned/getting high helps sleep use with other people Good sex Relief from anxiety

Fewer money problems Less likely to go to hospital Staying out of jail

Disadvantages

Health problems Keep losing jobs Get paranoid

Lose contact with friends No escape from depression Nothing to look forward to Having to cope with

Go round each individual whilst they are writing out some of their advantages and disadvantages helping them to think about each of the boxes to be filled in.

Was it harder to think about the advantages or disadvantages of using drugs or alcohol? BREAK Exercise 2: Thinking about advantages and discounting the disadvantages?

In this section, participants are invited to examine their distorted thinking about substances that maintains their substance use. This includes minimising the disadvantages associated with substance use and maximising the positives about substance use. They may also maximise what substances can do for them as they relieve some of the anxieties attached to certain situations. Open debate within the group and do not suggest or criticise answers.

Why do you use drugs and/or alcohol? Elicit answers and listen to different perspectives. This may seem like a stupid question, as the reason that most people give for using drugs and alcohol is for pleasure. But think we say that cigarettes give us pleasure, but think about them from a non-smokers point of view. Breathing hot smoke into our lungs, making us cough, giving us yellow teeth and bad breath. Does that sound enjoyable?

Can anyone think of other people’s drug or alcohol use that does not seem enjoyable? What about using needles? Drinking 1litre of cider first thing in the morning. It can be recognised that one person’s drug or alcohol use may seem awful to someone else. Drugs and alcohol do not give us pleasure, but only momentarily satisfy an addiction and reduce the feelings of craving which will only renew the addiction. For example, if smoking a cigarette was simply pleasurable, wouldn’t one cigarette satisfy us? Discounting the negatives:

Imagine that someone is thinking about using substances, do they worry about using how much it would cost?

Imagine that you are talking to a young person, would you recommend using drugs and alcohol? What would be the reasons that you would give them for using drugs or not using drugs?

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How do we know if our use of drugs and alcohol is a problem? What is a problem? Elicit some definitions of problems… Who do problems effect? Assignment question: Can anyone think of a problem that does not effect other people? Elicit a few responses without answering the question, ask participants to reflect on each others suggestion and think about how the problem may effect other people. Exercise 3: Looking for alternatives

This section uses the functional analysis in the last exercise with a view to increasing the advantages of not using substances and decreasing the advantages of using substances. It does this by looking for alternatives to drug or alcohol use.

Handout: Session 2 Function of Drugs and Alcohol

Organise the group into three teams 1. Each team should be given handout. All of the teams should write down some of the

advantages of using drugs and alcohol and the disadvantages of not using drugs and alcohol. (In each team, one person can write whilst others suggest ideas)

2. The handouts should be simultaneously passed round to the next team and all teams should complete section two: the function of drugs and alcohol.

3. The handouts should be passed around again and all teams should together come up with some alternatives to drugs and alcohol were these to cease to exist in the world.

Review the exercise and introduce assignments about personal use.

Assignment: What are the alternatives to drugs and alcohol

In the handbook list in the left column the advantages of using drugs or alcohol and the

disadvantages of not using drugs or alcohol. Write in the next column what function you think drugs or alcohol serves in your life. Write down some alternatives to this function in the third column.

Read through the examples in the boxes and practice with one personal example until everyone

understands the exercise.

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SESSION 3: Motivation to Change INTRODUCTION

This session explores the difficulties in changing addictive behaviour and looks at the variations in motivation to change over time. A model of addiction is presented in order to understand the reasons why it can be so difficult to change addictive behaviours. It examines the opposing thoughts and ambivalence in the process of change. Participants represent the opposing thoughts through debate and discussion in order to develop insight into the difficulties in initiating and maintaining change. Of particular importance is the group’s examination of the barriers to change and how motivation may be blocked or sabotaged. In this, it is particularly important to explore the myths (e.g. if I give up I will become a square), self-statements (e.g. I can’t give up) and scripts (e.g. I am ‘street’ and so I use drugs) involved in the change process. Key Issues: 1. Motivation to change varies over time depending on what happens to the person. 2. Motivational statements may help the person cope with the psychological barriers to changing

behaviour. 3. It is important to use open questions and avoid motivational interviewing traps (e.g. taking sides,

using question and answer, blaming, prematurely initiating change). Review Assignment: What are the Alternatives to Drugs and Alcohol?

Participants who have completed the assignment should be recognised and praised. If participants have not completed the assignment, they should be encouraged to complete them in the break. It is important to encourage the completion of assignments early in this programme and prizes can be given out for the people who have completed the exercise

What did you find was the most common function of drugs or alcohol for you? Invite participants to give at least one answer each. Exercise 1: Ever tried to change anything?

How many of you have ever tried to change something?

If nobody suggests any answers, use the example of New Year’s resolutions stopping smoking starting exercise etc. What did you remember about this? Ask about how they found this process of change. Was it difficult to change this behaviour? What types of things helped or prevented change. Ask about the role of thoughts and other people in this change?

Session Objectives 1. To understand the process of change.

2. Understand how motivation to change varies over time.

3. To examine how thoughts and actions vary with each stage of change.

4. To understand psychological barriers to change and how to overcome them.

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Exercise 2: What do you want to change? This exercise explores the substance use behaviours that the individual would like to change. This exercise focuses exclusively on substance use rather than any other behaviour, although it is recognised that other behaviours may need to change before addressing substance use (e.g. general lifestyle).

What drugs or alcohol were you using in the past? or What were your concerns about your use?

Individuals are requested to think about all of the substances that they have used in the past and consider which of these they would like to change. They should be encouraged to think about their use of substances at peak use. How bad did the problem get? At this point participants my not wish to share this information with other members of the group and want to only write it down in their workbooks.

What would you like to change about your substance use? or

How would you like to maintain the changes you have made? Participants are asked to think about changing their previous use of substances. If they have already made changes to their previous use either by cutting down or stopping use then ask how they intend to maintain this and what might be difficult in maintaining these changes.

What would things be like if you didn’t even want to use substances? or How is life different since you’ve changed using substances? In this exercise, participants are invited to close their eyes and reflect on what their lives would be like if they didn’t even want to use drugs or alcohol (including cigarettes) or what life is like now that they’ve stopped using drugs and alcohol. After a moments reflection, facilitators can ask participants to open their eyes and discuss what they imagined. These questions can include: How would you feel about yourself? / How would others feel about you? What would you be able to do differently (e.g. with more money, better health) BREAK Q: How important would you say it is for you to change your substance use? Exercise 3: Importance and confidence to change

This exercise is designed explore individual motivation to change substance use. It uses a number of exercises based on Motivational Interviewing. It explores the individual’s importance to change their substance use and what are the factors that would change this importance. Each of these exercises is written down in the handbook for completion after they have been discussed.

How important would you say it is for you to change your substance use? Explore some of the opinions within the group.

Write down on a scale from 0 to 10, how important is it for you to change your use of substances. 0 is “not at all important” and 10 is “extremely important”. 0 1 2 3 4 5 6 7 8 9 10

Not at all Extremely important important

Why do you think that it is this important to you?

Elicit reasons why individuals find it this important to change (e.g. to get out/stay out of hospital, get on with family, reduce mental health relapse).

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What do you think would have to happen in order for this to increase (e.g. become a 10)? Discuss what life events would have to happen in order for this to become more important to change (e.g. girlfriend said she would leave me

How confident would you say you are in changing your drug or alcohol use? 0 1 2 3 4 5 6 7 8 9 10

Not at all Extremely confident confident

What do you think could happen that would make you more confident about changing

your use of drugs or alcohol? (i.e. make this a 10) Exercise 4: Barriers to Change

This exercise aims to discuss the problems that may be encountered in the change process and how these might prevent change. At this stage, do not challenge the reasons given or the individual’s reluctance to stop using. This exercise aims to appreciate the difficulties that individual’s face in changing substance use and identify potential areas of relapse. What are all the reasons someone might give for not changing their drug or alcohol use? Discuss some of the reasons that individuals might not want to change (e.g. Self-confidence, no past success, not wanting to change, failed in past, like using substances, frightened what people might think)

Why don’t we change our use of drugs or alcohol? Try and find out all the things that can prevent us from changing our habits. Translate each issue into categories. E.g. “Don’t want to” “Our attitudes and motivation can prevent change” “I can’t change” “Beliefs about change can stop us from changing” “All my friends use” “In our current lifestyles do not allow us to change” State that we will be looking at each of these areas in the next session and further in Module 3: Relapse Prevention. Assignment: Myths about substance use

In this assignment, participants are asked to write down all of their thoughts: • What do substances do to/for them • The role of substances in society. • The use of drugs or alcohol as part of religion

What are your thoughts, beliefs about myths about drug or alcohol use E.g. Cannabis helps me to sleep,

Cocaine makes me more sociable

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SESSION 4: Overcoming Barriers to Change INTRODUCTION

This session builds on previous sessions examining people’s thoughts, beliefs and myths about drug and alcohol use and how this contributes to keeping them trapped in the cycle of drugs and alcohol, mental health problems and offending. This session emphasises the positive aspects of stopping substance use, rather than the negative aspects of giving up. This session is about gaining individual freedom from drug and alcohol use and all of the problems that come with it. It looks at how we create our own barriers to change through fear of change, and how to overcome these barriers. Key Issues: 1. Stopping using drugs and alcohol is not deprivation, but a benefit to the individual. 2. There are a number of myths, scripts and self-statements that may prevent or sabotage change.

Challenging these myths is part of the process of change. 3. Motivational statements may help the person cope with the psychological barriers to changing

behaviour. 4. Try to remember the “motivational hooks” or the main reasons each individual identifies for changing

their drug and alcohol use. These will serve as motivators throughout the programme. Exercise 1: Myths as brainwashing

This exercise introduces the session which focuses on the role of our thoughts and beliefs in keeping us trapped in the cycle of substance use. It develops a framework and understanding of substance use that can help to emphasise the importance of thoughts and beliefs in maintaining substance use. It is important not to argue with participants about their understanding of addiction, but to present the model impartially and they will make their own decisions about it.

There are two reasons why individuals use substance use: • physical addiction • brain washing

“The physical addiction due to the chemical reaction in the body. It is often very mild and doesn’t last very long. For example, Nicotine is a very short acting drug and levels in the blood halve within about 30 minutes of finishing a cigarette and quarter within one hour of finishing a cigarette. This would mean that you could never get to sleep because of the craving for a cigarette. Yet most people can survive during sleep, train journeys, in cinemas without cigarettes. The craving usually starts when you would normally have a cigarette as that is when you think that you need a cigarette. This is why brainwashing is so important in maintaining our substance use” “The addiction to drugs and alcohol lies in the brainwashing that surrounds their use. From a very young age we are told that cigarettes relax us, alcohol makes us happy, and cannabis is a soft drug, cocaine is fashionable. These messages can come to us from advertising, friends, parents social norms and they can be told to us or shown to us by others.”

We are going to look at the different types of addiction in the next module

Session Objectives 1. To promote a positive attitude to changing addictive behaviours

2. To challenge the thoughts, beliefs and myths that keep people trapped in the drug and alcohol use cycle.

3. To examine how thoughts and actions vary with each stage of change.

4. To understand psychological barriers to change and how to overcome them

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Exercise 2: What are your myths and how to challenge them?

This exercise reviews the assignment at the same time question some of the thoughts, beliefs and myths people have about drugs and alcohol. It aims to reframe the assumptions being made that support the use of drugs and alcohol. It is not necessary to question these assumptions directly or agree or disagree with any of the statements. The aim is for individuals to question their own assumptions. Point out any contradictions in the myths such as “cigarettes can help you relax” and “cigarettes can help you concentrate”. Two opposite functions in one drug. Magic! Point out any other magical thinking about the use of substances.

Invite each participant to read out their thoughts, beliefs and myths that support their use of drugs or alcohol. After each statement has been read, ask the rest of the group to think what a non-user would say to that statement. Would they agree or think the same thing?

Use the following examples as a framework to cue responses from other participants to think how non-substance users may think. E.g. Statement: “Cannabis helps me sleep at night” E.g. Response: “Non-cannabis users sleep.” “You sleep when you don’t have cannabis.” “You used to sleep before you had

cannabis.” “Cannabis doesn’t always make you sleep, it often depends on the type of cannabis or the amount you have.”

E.g. Statement: “Alcohol helps me to socialise” E.g. Response: “People in non-alcohol using countries still socialise”, “in a way you are socialising now without alcohol”, “too

much alcohol can make people very anti-social” Introduce some of the most common myths (if they haven’t been stated already), Ask the group to challenge these common myths.: “I use cigarettes, drugs or alcohol because I enjoy it” (Is putting a needle in your arm enjoyable? Waking up with a hangover? Bad breath? Headaches? Nausea? Irritabilitiy? Is staring at the TV for hours on end enjoyable?) “Drugs and alcohol relax me” (often they stimulate the central nervous system and can cause anxiety or paranoia) “Drugs and alcohol relieve boredom” (most people who sit round using drugs or alcohol are not doing anything interesting) BREAK Exercise 4: Undoing the brainwash

This exercise aims to explore individual approaches to dealing with some of the identified barriers to change. This exercise aims to recognise existing approaches rather than develop novel strategies. This can help to recognise the strategies that individuals have already developed.

How do we remove the brainwashing? It is important to think that we are not giving anything up. We are not losing anything, but gaining everything.

There are three things that we gain: 1. The return of our self-confidence and courage to achieve things 2. The freedom from slavery to our addictive self. 3. Losing the “black shadows” in the back of our minds.

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Discuss each of these points in turn: 1. Has anybody ever managed to stop a habit in the past? How did it feel to succeed stopping?

Relieved? Better? How did they feel about themselves whilst they had given up?

Stronger? More confident? “You do not have to be a strong person to overcome addictions, but stopping using drugs and alcohol will make you feel stronger in yourself as you will feel confident that you can do something that you want to do” 2. Has using drugs or alcohol ever stopped you from doing something?

Playing sport? Driving a car? Going to a non-smoking event? Going out with someone who does not use or like drugs or alcohol? Meeting people who do not like drugs or alcohol? Have drugs or alcohol ever made you do something that you didn’t want to do? Borrow money? Live on the streets? Commit an offence? Inject? Smoke?

“Drugs and alcohol can often limit our freedom and make us do something that we do not want to do. This is slavery. Stopping using drugs can free us from this slavery” 3. Have you ever felt that you shouldn’t have got stoned or drunk?

Done something stupid or reckless? Taken a risk with yourself or other people? How did that make you feel about yourself?

“Underneath the brainwashing most people know that using drugs or alcohol is not good for them or the people they care for around them. This can cause feelings of guilt, stupidity, failure. These are the black shadows in the back of our mind that stop us from feeling confident, free and happy”

Is there any thing else that we can gain from stopping? E.g. Health Courage

Energy Self-respect Wealth Happiness Peace of Mind Freedom Confidence

Assignment: Substance use and behaviour

Imagine that you are in the future and five years older than you are now. You have stopped using drugs or alcohol since the end of this group. Write a brief letter to your younger self (now) saying how much life has changed or improved since you last used drugs or alcohol. What sort of advice would you give your younger self to help stop using drugs or alcohol.

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MODULE 2: UNDERSTANDING MY SUBSTANCE USE

SESSION 5: What do drugs and alcohol do to me?

INTRODUCTION Drugs and alcohol change our brains as well as other organs of our bodies. This means that they can effect our physical and mental health. Substance use has an effect on both our physical and mental health. This session aims to understand people’s concerns about the effects of substances and why we sometimes chose to ignore these health warnings. Key Issues: 1. Develop an understanding of how substances work and what may be happening to us when we use

drugs and alcohol. 2. Low level of substance use or certain substances may lead to greater use, or use of stronger

substances. 3. Different levels of substance use can influence our thinking, behaviour and social perception which

individuals may not be aware of at the time of use. Review Assignment: What Advice would you give?

Review the questions from last week’s assignment:

Imagine that you are in the future and five years older than you are now. You have stopped using drugs or alcohol since the end of this group. Write a brief letter to your younger self (now) saying how much life has changed or improved since you last used drugs or alcohol. What sort of advice would you give your younger self to help stop using drugs or alcohol.

How has life changed in 5 years time?

What advice did you give yourself? Exercise 1: How do drugs or alcohol affect me?

This exercise aims to understand the neurological effects of both alcohol and drugs on the central nervous system and how this effects our experiences of the world around us. The information is presented on OHPs although it should be presented as a discussion rather than a lecture.

OHP Session 5 Presentation on substance abuse

What do people know about how drugs effect the brain? Different areas of the brain are associated with different functions. Drugs and alcohol act on the reward centres of the brain. Discuss some of the different areas of the brain. When you take drugs or alcohol, the substance passes from the stomach, lungs, nose and is passed into the blood stream where it is circulated to the brain.

Session Objectives 1. Understand what drugs or alcohol do to our brain function.

2. Find our what happens when we use drugs or alcohol over time.

3. Discover what happens when we stop using drugs and alcohol

4. Understand why drugs and alcohol are addictive.

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Drugs and alcohol effect the cells of the brain, neurons, by changing the amount of chemicals, neurotransmitters, passed between the cells. The main chemical effected by substance use is called “Dopamine” and is responsible for the reward function in the brain. Substances change the communication of neurotransmitters between cells by either increasing their production, increasing the rate at which they are received by the next cell or reducing the rate at which they are taken back by the previous cell (re-uptake). Substances therefore give us a sensation of pleasure as they stimulate the reward mechanisms of the brain.

OHP Session 5 Tolerance, Dependence and Addiction

The body responds to the use of substances and tries to re-establish a balance. It does this by counteracting the effect of the substance on the brain. This is why people become sober after some time. If you continue to use the same substance over a period of time the body will develop a Tolerance of the substance. This is where increased amounts of the drug are necessary to achieve the same effect. The body becomes dependent on the drug when the cells become used to the presence of those particular chemicals, and they become necessary for the normal functioning of the person. Addiction is when a person compulsively takes substances even when faced with negative consequences of that action.

Ask if there are any questions relating to this information. Break Exercise 2: Why do we enjoy using drugs and alcohol?

This section uses the neurological information about the effects of substances on the brain and challenges the point of view that drugs and alcohol are enjoyable, or that we couldn’t enjoy ourselves without drugs or alcohol.

OHP Session 5 Do we enjoy drugs?

A theory of addiction was developed after observing rats that could inject very small amounts of drugs into their brains when they pressed a lever. They found that when the drugs were injected into the brain at certain points along the reward pathway, the rats pressed the lever very fast.

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Divide the group into two ‘teams’:

One side of the team argues that the rat is enjoying using the drug and is pressing the lever faster. The other team argues that the rat does not enjoy using the drug and is only doing it due to addiction

Stimulus Questions:

Why do you think that the rat is pressing the lever? Is the rat free to chose if it presses the lever? Exercise 3: What is addiction?

This exercise aims to challenge some of the myths about addiction to substances. It breaks down the simple dichotomy between being addicted or not being addicted. It also questions the role of choice in using substances and the nature of relapse.

What does addiction mean to you? E.g. Enjoying doing something? Not having any choices? Needing to do something all the time? [Try to elicit what the word means to people rather than finding alternative words]

Has anyone ever been addicted to something? Does that mean that you always needed it, or only some

Is it possible to be addicted to things other than drugs or alcohol? E.g. chocolate, exercise, work, TV

Is it possible to be addicted to things other than drugs or alcohol?

OHP Session 5 Physical, Behavioural and Emotional Dependence

There are a number of different ways in which substances can be addictive, these include:

1. PHYSICAL ADDICTION. This can last for a short time after stopping to use substances, and is particularly notable in using. This is not the only form of addiction as anyone who has tried to stop using substances can tell as they often start using them again after several years. People can experience cravings for drugs and alcohol long after the substance has left their body. This is because there your body can remember the experience of the substance, particularly in certain situations people can often feel cravings as if they are withdrawing.

2. PSYCHOLOGICAL ADDICTION. This is the habit that arises from repeatedly using substances in situations. For example, smoking a cigarette with a cup of coffee, or smoking a joint at parties. We learn to associate certain situations or feelings with particular drugs or alcohol. Can you imagine going to the pub and not having an alcoholic drink? Could you imagine…(use examples from the group)? If so then you have become psychologically addicted to…

This is the emotional dependence we feel we have on certain substances. Give example: Someone once told me that giving up smoking was like losing a friend. We use drugs and alcohol to help us get through some of the difficult times like talking to a friend.

Assignment: Read Information on drugs and alcohol

Read the information in the participant handbook about drug and alcohol use.

There will be a quiz next time (Offer a reward for the most correct next time)

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Areas of the Brain and the Reward Mechanism

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What happens when we take Drugs or Alcohol

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How do Drugs and Alcohol Affect our Brains

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How Do Neurotransmitters communicate?

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SESSION 6: How do drugs and alcohol affect my mood and behaviour?

INTRODUCTION

Drugs and alcohol are psychoactive. This means that they have an effect on our brains that can change our behaviour, thinking, and emotions. This session aims to understand the effect of using substances on behaviour. Different types of drugs or alcohol are associated with different types of situations and behaviours. People describe different moods and behaviours when using drugs and alcohol. Some become sociable, others quiet and withdrawn or loud and aggressive when using substances. Moods and behaviours can often change as more drugs and alcohol are used. It can often be that problems do not arise whilst using substances, but after their effects have worn off. Key Issues: 1. Develop an understanding that some situations place individuals at greater risk of using substances

to excess. 2. Low level of substance use or certain substances may lead to greater use, or use of stronger

substances. 3. Different levels of substance use can influence our thinking, behaviour and social perception which

individuals may not be aware of at the time of use. Review Assignment: Quiz on substance use.

Handout: Session 5 Quiz Answer Sheet

Quiz: How do drugs and alcohol effect you?

Organise participants into several groups. Each team should give themselves a name Participants should close their handbooks. Read out the questions (answer sheets in handbook) : 1. Can cannabis help your memory? No 2. Which is worse for your lungs cannabis smoke or tobacco smoke? Cannabis 3. Roughly, how many chemicals are there in cigarettes? 4000 4. What is the abbreviated chemical name for cannabis? THC

[Extra point for the full name tetrahydrocannabinol 5. What is the name of any neurotransmitters affected by cocaine? Dopamine/Serotonin 6. What is dependence? Any correct definitions 7. What is tolerance? (relating to drug or alcohol use) Any correct definitions 8. Can cannabis effect your memory? Yes 9. What causes a hangover? Dehydration 10. What are the long-term effects of alcohol use? Liver/heart brain damage Read out answers Hand out prizes to the team with the most correct answers.

Session Objectives 1. Find out what happens to people when they use different amounts of different

substances.

2. Identify different behaviours at different levels of substance use

3. Identify any concerns about their behaviour after using drugs or alcohol.

4. Introduce links between substance use, offending and mental health

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Exercise 1: How do drugs or alcohol affect my behaviour?

The aim of this exercise is to develop insight into how individuals are when they are using drugs and alcohol to excess. Whilst many people think how they are after initial use, this section attempts to identify any concerns over excessive or chronic use. This exercise aims to use exaggeration and humour to emphasis some of the risks of using substances to excess. It starts with a discussion which is then organised onto flipchart. Role-plays are then used to reinforce the idea that changes in behaviour occur with the use of drugs or alcohol.

How do drugs and alcohol change my behaviours or actions? Introduce this exercise with a general discussion on how the person changes from the point of view of how others will perceive them. Participants may describe moods but make particular reference to what changes other people would be able to see and how that might affect other people. Ask participants what they are like at different levels of use.

Write down changes in behaviour at different levels of use in the Handbook.

How do drugs or alcohol affect me? Organise the flip-chart into the following chart and ask each participant to start to think about what they are like when they are using their drugs or alcohol. If a person uses more than one drug of choice (e.g. crack and cannabis) ask them to think about how each of these substances affects their behaviour. If participants use both drugs and alcohol, find out what they are like if they are using both.

Increasing Drug or Alcohol Use

‘Normal’

‘Tipsy’

‘Drunk’

‘Wasted’

Ask questions about each of the stages: • Does using this amount make you want to use more? • Does using make you do anything that you would not normally? • Are you able to make decisions about social situations as easily as usual? • Have you ever embarrassed yourself when you have been drinking? • Do you ever become paranoid when using drugs or alcohol? • Have you ever become violent when using alcohol? The group describes three levels of alcohol effects (e.g. tipsy, drunk and obliterated). Elicit behaviours at different quantities and how this affects individuals. The group describes three levels of cannabis effects (e.g. tipsy, drunk and obliterated). Elicit behaviours at different quantities and how this affects individuals. Ask the group to describe their behaviour at different levels of alcohol use. BREAK

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What are you like with different quantities of drugs or alcohol? If time allows, invite all of the participants to undertake one role-play each looking which demonstrates what they are like when they are using substances. Give each of the participants a particular scenario to undertake when they are at different stages of substance use:

• Buying a newspaper from a shop and talking to the shop assistant • Chatting up a girl/boy • Talking to the boss at work • Going to the job centre to ask for work.

Exercise 2: How do drugs or alcohol affect my mood?

The aim of this exercise is to think about some of the more internal changes that occur with using drugs and alcohol. It is worth linking the observed changes in mood with the bio-chemical changes that occur in the brain. This section examines some of the changes with substance use that occur that cannot be seen by other people.

How do drugs and alcohol change my moods or feelings? Introduce this discussion by asking participants to say what they are like if they stop using cigarettes. This can be either due to not having any or trying to stop. If participants have never stopped, ask what they think they would be like if they did stop. What changes in mood (e.g. irritable, annoyed etc). Then ask what people are like when they have used or are using substances. Responses may describe the “highs” immediately after using substances. However, the focus of this discussion in on the feelings afterward or when they are not able to obtain substances. Discussion needs to include both mood changes that can be seen (e.g. becoming irritated) and the ones that are harder to be seen (e.g. depression and withdrawal). This discussion also needs to differentiate between short-term and long-term effect (highs and hangovers) as well as one-off use and repeated use. There may also be mood changes around not using, or obtaining substances.

Complete questionnaire in handbook

Answer the following questions: Yes No Have you ever become irritable after using drugs and alcohol? Have you ever got into an argument after using drugs or alcohol? Do you feel that you can’t face people after using drugs or alcohol? Have you ever become short tempered if you haven’t had a cigarette? Do you ever get nervous with people when you have used drugs or alcohol? Have you ever been ‘unsettled’ if you haven’t got drugs or alcohol? Have you ever found yourself being uneasy if others are using drugs or alcohol and you are not?

Do you find yourself getting edgy when thinking about getting drugs or alcohol?

Has it been hard to face people when you are using drugs or alcohol? Have you ever found yourself not wanting to go out or see people when you have been drinking or using drugs?

If you have used drugs or alcohol regularly for some time, has this changed your mood?

Have you ever become depressed after using drugs or alcohol? Did you ever feel the need to use drugs or alcohol to cheer yourself up? Has it ever been hard to go to work or face people after you have been using drugs or alcohol?

Have you ever started to do things excessively after using drugs or alcohol (e.g. cleaning the house, talking fast)

Have you started to worry a lot about your health after using substances?

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Exercise 3: How can drugs and alcohol effect other people? This exercise looks beyond the person themselves to look at how it effects their immediate environment, work, family and friends. Some participants may report that it does not effect them in one domain, although it may have an impact on others. In the last session, we have looked at the potential impact on the person themselves. This exercise looks at the problematic effects of using drugs or alcohol whether it is due to binge use, repeated or long-term use. Participants will be able to draw their own conclusions about the impact on substance use on other people, although this exercise should be able to demonstrate that using drugs and alcohol does not only effect the person using it themselves.

Who do drugs and alcohol effect? Draw the following diagram and explain that each circle represents different areas of our lives going from that closest to us to the ‘bigger picture’ of the outside world.

How can using drugs or alcohol effect people’s immediate surroundings? What happens to the place where you live? (messy/tidy) Do you take as much care of yourself or your surroundings?

What can be the effect of drugs and alcohol on friends, family and relationships around you?

What happens in people’s relationships if they use drugs or alcohol regularly? How does your family treat you or you treat your family? Can using substances effect the way think about other people?

Does this have an effect on them? Have you ever felt that you have lost the respect of others due to using drugs and alcohol?

What is the effect of drugs and alcohol on work, society? What would happen if everybody used drugs or alcohol regularly? What can happen to your work performance?

Self

Immediate Environment

Family and Friends

Work and Society

e.g. offending

e.g. ignoring responsibilities

e.g. late for work

e.g. messy

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Are people who use drugs and alcohol more likely to offend? How could this effect society as a whole?

Participants write down in their handbooks for ten minutes how they think substance use has effected (or is effecting) areas of their life.

Assignment: Something regretted?

Introduce the assignment as a preparation for next week’s session: Drugs alcohol and offending

Answer the following questions:

1. Describe something that you have done in the past that you have regretted ever since, that occurred whilst using or withdrawing from drugs or alcohol

2. In this situation how did drugs or alcohol affect;

a. Your decision making? (e.g. I didn’t really think about the situation)

b. Thinking about the situation or person? (e.g. I thought that they were having a go at me)

c. Your moods? (e.g. I was feeling ratty or bad tempered)

d. How you felt about the person? (e.g. I just wanted them to go away)

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Session 5: Quiz Answer Sheet Team Name: ____________________________ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

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SESSION 7: How do drugs and alcohol affect offending and decision making?

INTRODUCTION

There are a number of ways in which substances use can affect others and link to offending. These include disinhibition leading to violence or sexually inappropriate behaviours, financial difficulties leading to acquisitive crimes, substance using and criminal lifestyle, deterioration of mental health leading, relationship difficulties or mood problems. This session aims to explore how substance use can lead to difficulties with others and can lead to crime. This does not necessarily indicate that everyone who uses alcohol to excess or illicit drugs becomes a criminal. Participants do not need to disclose their offence history in detail, although participants should have some appreciation that substance use not only effects themselves and their health. Key Issues: 1. This session is looking for links between substance use and offending by looking at patterns of

events rather than a direct or immediate cause between two 2. Many offenders use substances to counteract offending (e.g. cannabis to calm down) although the

gains from the substance use may be short lived leading to longer-term difficulties (e.g. bad mood in morning, no money).

3. For some participants there may be no connection between substance use and offending, although it is important to think of substance use as a risk factor to potential offending behaviour in the future.

Review Assignment: Something that you have regretted?

Answer the following questions:

Describe something that you have done in the past that you have regretted ever since, that occurred whilst suing or withdrawing from drugs or alcohol: In this situation how did drugs or alcohol affect;

1. Your decision making? (e.g. I didn’t really think about the situation) 2. Thinking about the situation or person? (e.g. I thought that they were having a go at me) 3. Your moods? (e.g. I was feeling ratty or bad tempered) 4. How you felt about the person? (e.g. I just wanted them to go away)

Ask participants to hold on to this example as we are going to come back to how drugs and alcohol can influence our feeling and thinking in offending…

Exercise 1: Types of offences

This exercise thinks exclusively about offending behaviours that can effect other people. This uses Socratic questioning to explore the links between different types of offences and substance use.

What are all the different types of offending?

Session Objectives 1. To understand the effects substances can have on others.

2. To explore different types of offending and how this can relate to substance use.

3. To develop and understand of the links between substance use and this offending history.

4. To understand the interplay between substance use, mental health problems and offending.

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List onto flip-chart all the different types of offences: Theft related offences: Robbery/burglary/Theft/Fraud Violence offences: Property destruction/Arson/ABH/ GBH/manslaughter/murder/kidnapping Sexual offences: Rape/exhibitionism/voyeurism/stalking Drug Related Offences: Dealing, possession. Motoring offences: Taking without consent, drunk driving Crimes of fashion: polar-neck jumpers, shell suits, floral dresses… Raise types of offences that may have not been identified (e.g. sexual) Exercise 2: How is offending linked to substance use?

Which of these offences can be related to drug or alcohol use? Use the list of offences to explore links with offending. This discussion is not about personal experiences, but about offending in general. Go through the list of types of offences and see which ones could be linked with substance use. For each offence type, question what the connection may be. If participants do not think that there is a link, give examples of how substance use could be linked to a particular behaviour:

1. Financial difficulties leading to acquisitive crimes 2. Disinhibited behaviour leading to violence or sexual crimes 3. Anger management problems as coping strategies are not used or less effective 4. Social misjudgement as things can be said leading to offending when drunk or stoned 5. Motor co-ordination problems leading to bumping into people or driving recklessly or carelessly 6. Mental health deterioration leading to irrational acts. 7. Impulsivity increases and people tend to think about consequences less? 8. Thinking can change, distorting the way that you understand a situation.

Conclusion: All offences can potentially be linked with substance use. BREAK Exercise 3: How is offending linked to substance use?

This exercise aims to explore further the links between substance use and criminal behaviours. It does this by looking at the changes in thinking styles and how that can influence a sequence of decisions.

Think about a crime that someone might commit Write on the top of the page an agreed example of a crime. Write down the steps involved in undertaking this crime.

e.g. Robbery 1. Thinking about committing a robbery 2. Making plans to carry out the robbery 3. Carrying out the robbery 4. Getting away 5. Avoiding arrest

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Role-play undertaking this criminal act under the influence of excessive drugs or alcohol. [Make sure that the role-play is safe and does not involve the use of violence.] Ask participants to role-play the steps identified on the flip-chart.

How did drugs and alcohol influence the decision making process in this crime?

On a parallel flipchart, look at how drugs or alcohol could influence thinking in the decision making process:

e.g. Robbery e.g. Increased need for money Not thinking about the consequences Poor thinking and concentration Increased impulsivity More aggressive Poor problem solving Not thinking about the victim Not thinking about alternatives

Any complete action is a series of decisions. Drugs and alcohol can influence our thinking that

can distort some the decisions that are made and increase the chances of committing a crime. Assignment: Vulnerability and protective factors

This assignment introduces the next session. Participants are asked to describe the things that make their mental well-being better and the things that make their well-being worse. This can include situations, people, events, etc. [Do not introduce the terminology: “vulnerability and protective factors” until next session.]

What are the type of things that make your mental health better or worse?

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SESSION 8: Do Drugs and Alcohol affect my Mental Health? INTRODUCTION

This session aims to look at how substance use can lead to increased mental health problems leading to re-hospitalisation. It looks particularly at the effect of cannabis and how it has particularly been connected to mental health problems. Key Issues: 1. Cannabis use has an impact on the relapse rates and readmission to hospital. 2. There can be a vicious circle between mental health symptoms and drug use through self

medication. 3. Review Homework: Vulnerability and Protective Factors in exercise later in the session Exercise 1: Do drugs or alcohol affect your mental health?

Debate: Do drugs and alcohol effect your mental health?

Divide room into two groups. Do not divide the groups according to what they do or do not believe about mental health and illness as arguing against personal beliefs can help to get a broader understanding. Each group has five minutes to prepare one of the following arguments using examples to back up their argument:

1. Drugs and alcohol do not affect mental health 2. Drugs and alcohol do affect mental health

It is not always clear if drugs and alcohol affect mental health symptoms and different people have different experiences and different understanding of their substance use. Some useful debating points may be:

1. Do you have to have a mental health problem for drugs or alcohol to effect you? 2. Are drugs or alcohol ever good for your mental health? (Is this in the short-term or in the long-

term?) 3. Would you recommend to someone with mental health problems that they should or shouldn’t

use drugs or alcohol? 4. Do different levels of drug and alcohol use effect your mental health differently?

Session Objectives 1. To recognise when mental health is getting worse and the symptoms of mental

illness.

2. To be aware of the general effects of cannabis use on mental health, psychotic relapse and readmission to hospital

3. To understand how symptoms of mental illness can influence our tendency to use substances.

4. To understand how using substances can increase these symptoms of mental illness and precipitate relapse.

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Exercise 2: Do drugs or alcohol affect mental health and re-admission to hospital? This exercise aims to demonstrate the chances of being re-admitted to hospital should participants use cannabis. It should be introduced as a learning exercise but it can also be fun.

Cards: In the community / Back in Hospital

Session 8 Graph of readmission rates for cannabis users and non-users

Research has shown from people being discharged from hospital for mental health problems: OHP: 1) After 12 months only 15 % of non-cannabis smokers were readmitted after 12 months 2) After 12 months, 50% of cannabis smokers were readmitted to hospital

Demonstration exercise:

Still in the Community

Back in Hospital

1. Place one card for each participant in a bag: 50% marked “Back in Hospital” and 50% marked “Still in

Community”. 2. Ask each participant to take one. 3. Say: Imagine all of you use cannabis after leaving hospital, who is likely to be back in hospital

after 12 months? 4. Elicit from the group who is still in the community in 12 months time and who is back in hospital. 5. Explain that that is their chances of remaining in the community/hospital should they use cannabis on

discharge. Collect back the cards. 1. Place one card for each participant in a bag: 15% marked “Back in Hospital” and 85% marked “Still in

Community”. 2. Ask each participant to take one. 3. Say: Imagine that you don’t use cannabis after leaving hospital, who is likely to be back in

hospital after 12 months? 4. Elicit from the group who is still in the community in 12 months time and who is back in hospital. 5. Explain that this is their chances of remaining in the community if they don’t use cannabis. Collect back the cards

You are more than 3 times more likely to be readmitted to hospital in a year if you use cannabis.

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15

05

101520253035404550

Cannabis Users Non-CannabisUsers

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Exercise 3: How do drugs and alcohol affect medication?

What is the effect of Illicit drugs on medication? There is evidence that continual use or high levels of drug use can counter act the effects of medication. This means that in order to manage symptoms of mental illness: a) Higher levels of medication are needed to maintain mental health stability. b) Increased side effects of increased medication:

i) More tired and lethargic ii) More involuntary muscle movement iii) Poorer concentration and attention

c) More risk of mental health relapse BREAK Exercise 4: Do drugs and alcohol increase vulnerability to mental illness?

This exercise follows uses the same scenario and looks at the effects of using drugs or alcohol in to cope with difficult situations. We are attempting to look at how substances

OHP Session 8 John John is a mental health patient and has just been discharged from hospital. He has accommodation but very little money as there is a delay in his payments. His family comes to see him occasionally but he doesn’t feel that this is very often. He can’t find work and he has nothing else to do during the day. He doesn’t know anyone on the hostel and he has lost contact with his friends from before his admission. He knows that he has got to do a lot of things to get himself back on track, but he’s not sure if he can do them. He starts to worry a lot about his current situation and finds that he can’t sleep so he is getting irritable and depressed.

Draw a simplified scale on the flipchart. Following discussion, write down John’s vulnerability and protective factors on either side of the scale

In the situation described, what things (factors) were likely to increase John’s likelihood of developing mental health problems? These are called vulnerability factors.

e.g. Social Isolation: having no friends or family around him. No work: Not having anything to do during the day or

What things are likely to decrease the likelihood of John developing mental health problems? These are called his ‘protective factors’?

e.g. Having some family around. Living in a supported hostel.

Having some support from mental health services

What are the vulnerability and protective factors in your life? Complete exercise in the handbook.

Protective Factors Family Friends Money Accommodation Social life Medication

Vulnerability Factors Isolation Loneliness Paranoia depression

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Can increased drug and alcohol use tip the balance? How does using drugs or alcohol to excess change the vulnerability and protective factors? e.g. Less money and increased financial stress. Feeling more tired and not being able to get up.

Drugs and alcohol can put a lot of stress on the body trying to get them out of the system and they can also reduce sleep that can increase the stress on the body.

Why is it that some people can use drugs and alcohol to excess and not develop mental illness? All people can develop mental illness with increased stressors of decreased vulnerability. (e.g. sleep deprivation studies on soldiers found that they developed symptoms of psychosis after several days without sleep). Differences in vulnerability. Some people have a genetic vulnerability to stress meaning that they are more likely to develop psychosis Differences in protective factors. Some people have better support or coping that can help them manage the negative effects of drugs and alcohol.

All people are vulnerable to developing symptoms of psychosis, but some people are more vulnerable than others to symptoms of mental illness. Assignment: How do drugs and alcohol affect your mental health?

This assignment is designed to consolidate the session by asking participants to review the EWS checklist the last time that they felt that their mental health got worse. Participants do not need to acknowledge that they have a diagnosis or a psychotic disorder as everyone has times when their mental health deteriorates. They just need to recognise that their thought, perceptions, feelings and behaviours change when they are under stress.

Complete Early Warning Signs checklist.

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Still in the Community

Back in Hospital

Still in the Community

Back in Hospital

Still in the Community

Back in Hospital

Still in the Community

Back in Hospital

Still in the Community

Back in Hospital

Still in the Community

Back in Hospital

Still in the Community

Back in Hospital

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SESSION 9: How do drugs and alcohol cause mental health relapse?

INTRODUCTION

Earlier in the module, the group has examined the effect of drugs on the brain and how substance use can effect mental states. This session look at some of the connections between mental health problems and drugs and alcohol use. This includes using drugs and alcohol as self-medication to cope with the distress and the symptoms of mental illness and it looks at the substance use in terms of the stress-vulnerability model of mental illness. It is not as important that participants can describe these theoretical models as that they understand how substance use and mental illness can be linked. Key Issues: 1. There is an important interaction between increasing levels of social and/or psychological problems

and increased drug use, which in turn can lead to increasing levels of social/psychological problems. It is important for individuals to recognise this vicious circle in as part of an increased likelihood of escalating mental health relapse and offending.

2. The connection between drugs and mental health relapse is not a simple unilinear relationship. Understanding this relationship with the stress-vulnerability model of psychosis as well as social problem solving models is designed to increase participant’s insight into why they use drugs on occasions.

3. Homework is reviewed as part of exercise one. Exercise 1: What are your early warning signs?

This section aims to review participants understanding of their Early Warning Signs (EWS) that their mental health is deteriorating. The focus on this exercise is not to look at the negative aspects of mental health problems, but that by monitoring mental health problems they can be kept in check. Many participants may not think that they have a mental health disorder, and so it is important to emphasis that we all have mental health, and just like physical health this needs to be monitored and managed. Most EWS would be associated in some way, but it is important that participants start to think about the connection In this section we are going to look at the effect of the onset of early warning signs on high-risk situations.

What are Early Warning Signs? (also in handbook) These are changes in thinking perception, feeling and behaviours that can come before a deterioration in mental health and symptoms of mental illness.

Session Objectives 1. To understand how symptoms of mental illness can influence our tendency to use

substances.

2. To understand the idea of self-medication and how psychological problems can be self-medicated in order to reduce distress

3. To understand how drugs can increase stress through loss of sleep and other behaviours which can precipitate a psychotic relapse according to the stress vulnerability model.

4. To understand about vulnerability and protective factors and how increased drugs and alcohol can effect these factors

5. To understand how using substances can increase these symptoms of mental illness and precipitate relapse.

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1. Early warning signs are the changes in thinking feelings or behaviour that come before a mental health relapse.

2. 70% of patients and 90% of their families said that they could predict when a mental health relapse was about to occur due to these changes in thinking, feeling and behaving.

3. For most people this causes a great deal of anxiety in thinking “Am I going crazy?” or “What is happening to me?”.

4. By knowing our early warning signs and how they effect us, we can take action early to prevent a mental health relapse.

How do you know when your mental health is starting to deteriorate? What changes in your thinking feeling and behaviour when your mental well-being starts to get worse? Participants should use their early warning signs checklist to answer these questions.

Which one of these early warning signs could be associated with the use of drugs or alcohol?

E.g. Staying at home more -> smoking cannabis and watching TV Social Withdrawal -> using cocaine to socialise Feeling anxious -> using alcohol to relax

Place a next to all the early warning signs that could be associated with drug or alcohol use and a next to the one that wouldn’t. Conclude

Exercise 2: Drugs and alcohol as Self-medication?

This exercise uses the character from session 8 to continue to build up a picture of a situation associated with a high risk of mental health problems. This scenario is the building block for both the self-medication and stress-vulnerability models.

OHP Session 8 John Read out the scenario to remind participants.

How does John feel in his current situation? Build a picture of John’s internal world and possible emotions:

e.g. Depressed. Lonely. Anxious. Stressed-out

Do you think that John is more likely to use drugs or alcohol in this situation? Why do you think that would be?

e.g. To help him sleep. As a way of coping with feeling down. To try and pick himself up. This is called Self-Medication when you use your own drugs or alcohol to cope with personal problems. This is similar to the way we use other medications to cope with problems.

What do you think would happen if he started to take drugs again? e.g. Have less money and become more stressed. Get more anxious about his situation. Become more lethargic and not look for work. Start to become paranoid. BREAK

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Exercise 3: The vicious circle of drugs alcohol and mental health problems? This exercise leads onto exercises about mental health relapse next session by looking at a vicious circle of changes in mental health problems and substance use that can lead to mental health relapse. This uses the scenario started in the first half of the session and continues to develop the idea that people use substances to cope with mental health problems, but that these lead to increased mental health problems, creating a vicious circle.

What would happen if John started to use drugs or alcohol to cope with his increasing difficulties?

OHP Session 9 Vicious Circle

Vicious Circle

There is an example of the types of ways that drugs and alcohol can make stress work

Ask participants to think about the last time they were using drugs or alcohol and this effected their mental health or… Ask them to complete their own vicious circle of this situation that could have lead them in the past to use drugs or alcohol and lead to mental health problems.

This situation can be a real example from the past or a hypothetical event. Exercise 4: How to get out of the vicious circle?

This builds on the previous exercise by looking at the exit points in the vicious circle. Participants may have had experience in getting out of this downward spiral and can contribute from their own experience.

How do we get out of this vicious cycle? Go around the circle and think about the actions that can be taken at different times to get out of this situation

Vicious Circle

Stress

D & A use

EWS problems

Stress

EWS problems

E.g. Cope with stress Relaxation Talk to people. Get help

D & A use

E.g. Talk to doctor Change medication Manage symptoms

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Get as many examples of what can be done to get out of the vicious circle. These can be as creative or ridiculous as you like, but the important thing is to understand that something can always be done in situations.

Ask participants to write in possible actions on the diagram in their handbook.

Assignment: High Risk Situations?

What are the situations or thoughts or moods when you would be most likely to consider using drugs or alcohol again?

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MODULE 3: RELAPSE PREVENTION SESSION 10: What is Relapse Prevention? INTRODUCTION

This is the start of a new module looking at relapse prevention. In this module we are going to be looking at our thoughts and behaviours that place us at high risk of using drugs and alcohol. This session aims to identify high-risk situations and thinks about ways in which people consciously or unconsciously set-up situations in which they are likely to use drugs or alcohol. This module also introduces some of the ways in which we can reduce our risks of starting to use drugs or alcohol again. Key Issues: 1. There are certain thoughts, behaviours and situations that place us at high-risk of starting to use

drugs or alcohol again. Recognising our own high risk situations can help us to 2. Sometimes we can unconsciously or consciously increase these risks in order to use drugs or

alcohol. 3. Throughout these sessions the word relapse refers to renewed use of drugs and alcohol over time.

Substance use relapse must be differentiated from mental health relapse, although the two events may occur simultaneously.

4. The expressions slip, refers to a momentary lapse from drug or alcohol abstinence. It is important to differentiate this expression from a more enduring relapse that individuals may feel is less changeable.

5. Homework is reviewed in exercise 2 rather than at the beginning of the session. Exercise 1: What does relapse or relapse prevention mean?

This exercise introduces the concepts and terminology involved in relapse prevention as a common language for the group. Present the concept of Relapse Prevention and invite group to give their understanding before giving explanations and clear up any misunderstandings. Make sure that participants are not confused between substance use relapse prevention and mental health relapse by exploring the common idea of things getting worse or deteriorating in both situations.

OHP Session 10 Mountain Staying off drugs and alcohol is like climbing a mountain. This may seem daunting when you are at the bottom, but as you climb, you get so many advantages: • A better view • Clearer air • Feeling better

OHP Session 10 Relapse prevention

Introduce the picture as the process of relapse prevention. Climbing the mountain is the process of moving away and “Staying Free” from drugs and alcohol. The steps towards “staying free” are highlighted in blue, describe each step and state that this will be covered in the Relapse Prevention module. Highlighted in red are the risks involved in staying off drugs and alcohol,

Session Objectives 1. To introduce the concept of relapse as a process and relapse prevention.

2. Identify high-risk situations that could lead to drug or alcohol use.

3. Give overview of the ways of coping with high-risk situations

4. For individuals to look at the types of processes involved in relapse and relapse prevention

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including high-risk situations, slips and drug thoughts. Highlighted in green are the steps to staying free: • Planning for high risk situations • Avoiding high risk situations • Managing stress • Managing thoughts and moods • Getting Social Support • Getting back up again after a slip • Staying free

What does Relapse Prevention mean?

Stopping yourself from relapsing back into drug and/or alcohol use. Relapse means letting things get worse or decline. In the case of substance use, starting to use again.

What does abstinence mean?

Abstaining from drugs or alcohol means that you have stayed free from drugs or alcohol for some time.

What is the difference between having a slip and having a relapse?

When we first use drugs and/or alcohol after some time it is called a slip. If this slip then turns into renewed use of drugs or alcohol, then this becomes a relapse.

Exercise 2: Review Homework - Describe a relapse situation?

This exercise aims to look at a past event when someone had wanted to change and then used drugs and alcohol anyway. Individuals can use the homework to identify situations that they

In pairs describe to the other person a situation when you had tried to stop using drugs or alcohol and then started again?

On flipchart, write a list of the questions for each person to ask the other person in the pair: 1. What was it that they were trying to change in the first place?

E.g. using cannabis daily 2. Why were they trying to change it?

E.g. It was starting to give me headaches 3. What types of things made them restart the behaviour?

E.g. argument with girlfriend 4. Were there any triggers associated with starting again?

E.g. Seeing someone smoking 5. How did they feel about not stopping?

E.g. Felt like a failure Exercise 3: What are your High Risk situations?

This exercise aims to identify the high-risk situations associated with substance use relapse. For each person in the group this can be different and everyone should have their own high-risks. The purpose of recognising high-risk situations is so that we can also avoid typical reflex reactions that lead us to using drugs or alcohol. High-risk situations are the result of high-risk places, things, people thoughts and moods. Invite participants to give their own examples for each high-risk category before completing the written exercise

What are the typical high-risk places and objects for people in general? High-risk situations are places or things that can increase the risk of using substances. This can include being in places that are associated with using drugs or alcohol (e.g. pubs) This association can stimulate feelings of craving that can place people at risk. We will be looking at how to deal with cravings later in the programme.

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What things (cues) make you think about drugs or alcohol putting you at high-risk? This includes seeing things that remind you of using substances (e.g. cigarette packet, needle).

Who are the high-risk people that can increase the risks of relapse? This can include friends or other people that use or have drugs or alcohol.

What are high-risk thoughts that can increase the use of substances? High-risk thoughts are things that people say to themselves that include: Thoughts that minimise the harm caused by drug and alcohol use (“it won’t do me any harm”). Thoughts that normalise the use of drugs or alcohol (“everybody does it, why be different”) Thoughts that justify use (“I need a drink”; “I deserve a smoke after work”; “One for the road”). Thoughts that deny use (“I’m not using regularly”; “I’m not really a user”)

What are high-risk moods for people in general? Typically, extreme moods or feelings can lead to high risk situations including being very happy, or very sad, high levels of stress (losing job) or extremely low levels of stress (being on holiday) have been associated with increased substance use. When participants identify problem situations, ask them about the opposite situation. Mentally disordered offenders are typically less likely to recognise the role of moods and mental health in their use of substances and this may need to be introduced.

Write down your own high-risk situations in your handbooks. Rank how risky each of these situations would be to using drugs or alcohol.

Check that each participant is able to recognise difficulties in all categories of high-risk, including situations, moods, thoughts and people. It is important to prioritise our high-risk situations as our actions in each of these situations will be different. Introduce the next exercise prior to the break so those participants can prepare.

BREAK

Role-play a high-risk situation? Invite each participant to role-play one of their high risk situations either by talking through the situation at the front of the group or by acting it with another member of the group. The role-play should conclude with each person saying or doing what they would typically have done in the past. (We will be looking at alternative responses in session 13.) At the end of each role-play, ask the other participants if they would find that situation difficult. Discuss what factors made that a high-risk situation.

Exercise 4: What are the ways of coping with high-risk situations?

This section gives an overview of the relapse prevention and skills development modules in order for participants to start to think about the skills they want to develop to reduce their risks of drug or alcohol relapse in the future.

What can we do in these high-risk situations? Using each of the high-risk situations that were role-played in Exercise 2, invite the group to think of ways of coping with individual situations that would not involve the use of drugs or alcohol. Elicit ideas form the group and write them on a flipchart. Invite participants to imagine a high-risk situation.

Categorise the coping mechanisms:

1. Identifying high-risk situations and PLAN alternatives 2. Avoiding putting yourself in high-risk situations

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3. Managing lifestyle stress 4. Managing emotions and moods 5. Changing our thinking about drugs 6. Changing our lifestyle

Assignment: Thoughts that justify substance use

This exercise is preparation for the next session: How can my thoughts make me relapse. It builds on the myths that were discussed in session 4 and moves to exploring more personal thinking about use of drugs and alcohol.

Think of all the expressions you have heard of that can support the use of drugs and alcohol. E.g. “One for the road” What are all the things you say to yourself when you use drugs or alcohol? What does your internal voice say when you are about to use drugs or alcohol? E.g. “What the hell”

“Everybody smokes cannabis”

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SESSION 11: How can my thoughts make me relapse? INTRODUCTION

This session looks at the role of thoughts in putting us in high-risk situations. It does this by looking at the typical expressions and phrases that encourage the use of drugs or alcohol, and how these can get inside us. It also looks at our own thoughts that can encourage us to use drugs or alcohol. This is the “brain washing” that was described in session four. In this session we go on to challenge these automatic thoughts and look for more rational responses. Key Points:

1. There is a link between the common expressions people use to justify the use of drugs or alcohol and the internal voice that encourages their use.

2. Homework is reviewed as part of exercise 1.

Exercise 1: How can our thoughts put us at high-risk of using drugs or alcohol?

This exercise identifies the different types of thoughts that encourages the use of drugs or alcohol. It does this by classifying them and then exploring how useful these thoughts are in achieving aims and objectives. This exercise looks at six types of thoughts that encourage the use of substances, although it needs to be recognised that there are other types of cognitive distortion that can increase the use of substance use.

Have you ever heard the expressions: “I’m really stressed I need a cigarette” “I need a drink to help me unwind” “Let’s party” “One for the road” These expressions support the use of drugs and alcohol. Elicit any other expression that participants may have heard and recorded as part of their assignment.

Do you ever use expressions when you are using drugs or alcohol that encourage their

use? Find out personal examples of expressions used by participants. E.g. “I’ve had a hard day, I need a drink” “Everybody here is out to party” “I can’t help it, I just want to have a drink” “It’s not a drink if it’s only a half” “A man needs to relax after work” “Everybody is drinking. I’m not going to get on with anybody unless I drink” Elicit all the personal expressions that participants have written down for their assignment.

Session Objectives 1. To find out what is the role of our thoughts in putting us at high-risk of using drugs

and alcohol. 2. Look at our own automatic thoughts when using drugs or alcohol. 3. Learn how to respond to automatic thoughts that put us at high risk of relapse. 4. Learn to monitor our thoughts that put us at high risk of relapse.

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These statements encourage us to use drugs or alcohol can be categorised into different types of thinking styles:

Justification:

This includes things that we say to ourselves that justify the use of drugs or alcohol, and give us a reason for using.

Minimisation:

These are the thoughts that make us think that the effects of drugs or alcohol are not as bad as we know that they can be, or that the personal consequences are not as bad.

Normalisation:

This is when you tell yourself that it is normal to use drugs or alcohol as everyone else does.

Denial:

This is when you tell yourself that you are not using drugs or alcohol when really you are. Helplessness: This is when you tell yourself that you don’t have a choice when you use drugs or alcohol. Exaggeration: This is when you tell yourself that something really bad will happen if you don’t use drugs

or alcohol.

Copy down the expressions from the flipchart putting them into the six categories in your handbook.

Why do our thoughts encourage us to use drugs or alcohol?

Whenever we use drugs or alcohol knowing that it is bad for us we need to justify its use to ourselves. Sometimes we do this unconsciously, when we are not aware that we are encouraging ourselves to use

BREAK Exercise 2: Challenging our automatic thoughts

This exercise demonstrates the steps to making rational responses. These are the steps suggested in Beck et al (1993) Cognitive Therapy of Substance Abuse (Chapter 9). However, you need to be as creative as possible in challenging some of the automatic thoughts that support the use of drugs and alcohol.

How do we challenge our automatic thoughts? There are six questions you can put to yourself:

1. What is the evidence that the automatic thought is true? E.g. “If I didn’t get a drink, then I would still be OK”

2. Is there an alternative explanation? E.g. “Maybe I just want a drink because I’m feeling down”

3. What’s the worst that could happen? Could I live through it? E.g. “If I don’t get a drink, I’m not going to die”

4. What should I do about it? E.g. “I’ll can just have a drink of soda and lime to refresh me and then I’ll feel better”

5. What’s the effect of believing my automatic thought E.g. “If I believed my automatic thought, I would just go and have a drink”

6. If a friend of mine / family member was in this situation and had this thought, what would I tell him/her? E.g. “I would tell them that they don’t really need a drink, they just think that they need a drink because they are

craving”

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Go through each of the six questions using the examples given. Ask if there are any other questions you can put to yourself to challenge these automatic thoughts.

Invite participants to challenge their own automatic thoughts using the six questions in their handbook.

Exercise 3: Role-Play: Giving rational responses?

This exercise introduces the use of thought monitoring and challenging thoughts to change the automatic thoughts associated with drug and alcohol relapse. It uses role-plays in which one participants reads out the automatic thoughts and the other develops the rational responses: the two aspects of thinking. If some participants cannot read the scripts they can develop the rational responses.

One role-play script for each participant

Role-play in pairs: #1 reads out the script. #2 provides some rational responses Assignment: Thought records

This is a complicated assignment and enough time will need to be allocated to describing how to use this diary over the next few days. Go over an example from the recent past to complete the first line of the diary.

Monitor your own automatic thoughts over the next week about your drug and alcohol use. If you do not have any thoughts about illicit drugs or alcohol, think about your use of cigarettes or coffee if you do not smoke. Look for alternative thoughts to these automatic thoughts when you recognise an automatic thought.

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SESSION 12: How can Unconscious Actions make me relapse? INTRODUCTION

This session aims to understand how unconscious processes can increase the risk of starting to use drugs or alcohol again. Even when we don’t want to use substances, sometimes we can set up situations without being aware of them. Sometimes we just don’t think and act on impulse that starts us using drugs or alcohol again. This session look at how we can set up High-Risk situations that place us at risk. It also looks at how we can impulsively give in to our desire to use drugs and alcohol. Key Issues: 1. We are not always aware when we are placing ourselves at high-risk of using drugs or alcohol 2. We can become aware of when we are unconsciously putting ourselves at high-risk by thinking about

the consequences or our actions 3. We can only change our unconscious actions when we become aware of them Review Homework

Review the automatic thought diaries. If participants haven’t completed this, spend 5 minutes at the beginning of the session to complete this. Ask for an automatic thought and the rational response from each of the participants.

Provide additional thought monitoring sheets if anybody would like to continue to develop their rational responses.

Exercise 1: What are Unconscious Actions?

These first two exercises start to explore unconscious actions that may place the individual at high-risk of using substances. It does so by using a hypothetical scenario starting off the day by planning not to use substances and ends up in a high-risk situation. Using a time line explore the type of unconscious decisions that may be involved in this process.

What are Unconscious Actions? 1. Unconscious Actions are the things that just seem to happen. 2. They are unconscious actions that lead us to what we want (desires) and away from what we

don’t want 3. Although we are not aware of these actions, we can make ourselves aware of them and change

them. E.g. Turning our back on someone when you don’t like someone Looking away when you don’t want to listen to someone Crossing the road for no apparent reason when there is a dark alley way in front

Session Objectives 1. To introduce the idea of thoughts influencing relapse

2. To review high-risk situations.

3. To find out how Unconscious Actions can place us at high-risk of lapse or relapse.

4. To explore the role of moods in the relapse process

5. Examine how moods can be created to justify relapse.

6. Look at how self-statements can influence/justify relapse.

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Making eye contact with someone when you like them Ask the group to give other examples. Exercise 2: How do Unconscious Actions effect drug and alcohol use?

Describe a Scenario: John is trying to stay away from using crack cocaine. One day he is sitting in his flat and later that evening he finds himself in a situation where he is at high-risk of using drugs or alcohol. Describe how he might have come to be in this high-risk situation. What are all the unconscious decisions/actions that could have led him to be in this situation?

Draw Diagram (also in handbook)

1. Draw diagram of process leading to high-risk situation. 2. Ask what might be the consequence of each of these unconscious actions 3. Ask if unconsciously these decisions would lead to a high-risk situation. 4. How could conscious actions have avoided high risk situations or reduced the risk. Write

alternative below on the diagram and copy into handbooks . 5. Get examples of unconscious decisions that can occur in other situations until all members of the

group understand and are familiar with the situation.

What are all the different types of unconscious decisions that can lead to high-risk situations?

1. Setting up situations E.g. visiting friends that might have drugs

2. Setting up moods E.g. Starting an argument that will lead to anger or bad moods

3. Setting up thoughts E.g. Only reading articles that show that everyone uses drugs or alcohol or looks at the benefits of using.

Exercise 3: What are my Unconscious Decisions?

This exercise aims to practice recognising the process of making unconscious decisions. Give a personal example relating to something legal (e.g. shopping) so that participants can understand the process by which we set situations up. It is important to understand that we don’t just do this in relation to drugs and alcohol, but other issues such as arguments and disappointments as well. Give Personal Example: E.g. I was on my way home from work the other day and I found myself looking in shop windows. I hadn’t planned to buy anything but something caught my eye and I wondered in the shop. Before I knew it I was buying a new shirt/dress/shoes etc. I think that I had unconsciously put myself in a position where I was going to spend money when I didn’t want to. I think that this was an unconscious decision.

Had argument with girl

friend and went out

Walked our with all his money in pocket

Walking through drug dealing part

of town

Meeting with substance

using friendsNot planning

the day

HIGH RISK SITUATION

Sitting in Flat

ABSTAIN

RELAPSE

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Think of a situation where you unconsciously decided to use drugs or alcohol

Exercise in handbook 1) Think of a situation in which you lapsed or relapsed when you were hoping to give-up drugs or

alcohol. 2) What were the unconscious decisions that led up to that event? 3) How did your unconscious decisions put you in a high-risk situation? If they cannot think of or remember a past situation, ask them to imagine a situation in which they might lapse. If they cannot think of any unconscious decisions give some examples. Exercise 4: Coping with Unconscious Actions?

We can cope with Unconscious Actions by recognising when we are setting up a situation and making turning this into a Conscious Action. If it is not a conscious decision we want to make we can start to challenge our thoughts and change our actions.

What can we do about our unconscious decisions if we are not aware of them?

How do we prevent unconscious decisions 1. Make Unconscious Actions conscious. We can do this by working out the consequences of our

actions and if we are setting ourselves up to use drugs or alcohol. 2. Recognise our high-risk situations. By recognising the situations moods and thoughts that put us

at high-risk of using drugs and alcohol, we can recognise if our unconscious actions are putting us at risk.

3. Planning to avoid high-risk situations. By making a plan to deal with situations, moods and thoughts we can avoid the consequences of our unconscious decisions.

BREAK Exercise 4: The Problem with Impulsiveness

This exercise identifies the thoughts that occur at the time of lapse when the individual is thinking about the immediate situation and immediate rewards. It aims to look at strategies for coping with the including thoughts and behaviours that can help to avoid a lapse.

Has anyone ever said to themselves “What the hell” and then gone and found some drugs? Discuss personal experiences.

What does “What the hell” mean when give up giving up?

Elicit the possible implications of saying “What the hell”: e.g. “I’ve got nothing to lose... “I don’t care any more (to myself or others)…” “Let’s take a risk…” “I don’t want to give up any more…”

What’s the difference in your thinking when you say “what the hell” up and when you decided to give up?

Elicit ideas from the group with guided discussion about the following: 1. Looking only at short-term rewards 2. Discounting the short-term negatives effects 3. Not looking at long-term negative consequences

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Exercise 5: Coping with Impulsivity This section looks at each of the participant’s ways of dealing with impulsive situations. The aim is to build on these skills by introducing the red flag. This means danger or stop. The concept of the red flag will be introduced later in the programme in relapse prevention planning.

How do you maintain abstinence at this point? Elicit ideas from the group about what action or thoughts can be taken at this point to maintain relapse.

e.g. Leave the situation quickly and do something nice (healthy) instead. Remind yourself of the self-statements that help to remain abstinent. Contact family or (non-drug using) friends or support worker.

Red Flag: 1. Stop thinking about drugs or alcohol and think about something else 2. Think about your positive goals in life and where you want to go 3. Think about consequences (Think about hospital, prison) 4. Leave the situation that would put you at high-risk of using drugs or alcohol 5. Do something nice with the money instead

It would be helpful to make up some credit card sized “flashcards” with the red-flag on one side and either the above list of instructions or self-statements on the other side. Assignment: What to do in high-risk situations?

This assignment is preparing for planning relapse prevention strategies in the next session. It looks at what are the options when people feel an impulse urge to use drugs or alcohol.

Make a list of all the actions can you take when you get the urge to use drugs or alcohol.

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SESSION 13: Relapse Prevention Planning INTRODUCTION

The purpose of this session is to develop a Relapse Prevention Plan for each participant of the group. This relapse plan should be shared with your care co-ordinator or primary nurse at this stage. The relapse prevention plan is built on information from all of the session in the first three modules. This session goes on to review the skills that are needed for this plan and how these can be developed in the next 10 sessions. Key Issues: 1. Planning is the key to managing high-risk situations. 2. In order to plan for high-risk situations we need to be able to recognise what are these situations. 3. Different actions will be helpful at different levels of risk. 4. By evaluating how these plans work we can review our plans for the next time. Exercise 1: Why make a plan?

This exercise introduces the concept of planning.

If you wanted to climb a very high mountain, what would you do? Elicit spontaneous responses and question each of them leading to the need for planning: E.g. Start climbing -> What happens when you get lost Get a map -> If you find your way you wouldn’t have the equipment Organise an expedition -> What is the essential part of organisation? PLANNING is the most important part of a successful operation Exercise 2: What actions can be taken as part of this plan?

This exercise uses examples of risk situations to generate some of the actions that can be taken when faced with high-risk situations. It is important that participants are realistic in their ability to cope with situations and don’t give overly rigid or black and white responses to high-risk situations (e.g. I’d just walk out) that are unlikely to happen. It does this by looking at outcomes from different alternatives to high-risk situations. This can be described as a win-win situation (e.g. don’t use drugs and keep friends) rather than a win-lose situation (e.g. stop using and lose friends or start using again and keep friends). 1. What are the things that you can do in different high-risk situations

Ask participants to go back to their handbooks for session 10 and look at the high-risk situations that they have described. Get them to describe of one high-risk situation and how they would deal with it.

Session Objectives 1. To understand how planning can help us in high-risk situations. 2. To think about how our plans need to be different depending on the level of risk in

each situation. 3. To make emergency plans for impulsive situations. 4. To look at the skills that we need to develop to help us plan for high-risk

situations.

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2. What would be the outcome of these actions? Think about the outcome of managing the high-risk situation. If the outcome means that they have lost a friend by walking away from them or not enjoyed themselves as they have just left the party then it is going to be difficult to maintain these strategies and still enjoy life.

3. What are your goals from this situations?

What do you want to achieve from the situation as well as not using drugs and alcohol? Do the actions achieve all of your goals? Could other actions could improve the outcome?

In the handbook:

1. Write down four high-risk situations that were described in session 10. 2. Rate the level of risk for each situation 3. Describe what they could do in each situation. 4. Evaluate the outcome of each risk-management strategy

BREAK Exercise 5: Role Play Risk Planning

If you think that there is time during this session, role-play a high-risk situation. Try experimenting with different strategies and evaluate their different outcomes.

Role-play For each persons role play:

1. Get them to describe the high-risk situation and arrange other people to play parts (this can be the same as session 10)

2. Get them to describe what their risk management plan and their goals from the situation. 3. Get them to evaluate the outcome of the risk management plan and how they might have

done it differently. Exercise 3: What should I do at different levels of risk?

Using the risk thermometer, this exercise starts by getting participants to recognise when they are at risk and what they can do at different levels of risk.

How do we know when things are getting really risky? What are all the signs that we are starting to feel tempted 1. Mental (E.g. “It would be really nice to have a joint right now”) 2. Physical (E.g. “Start to get irritated” or “Getting butterflies”)

Our actions in different situations should change depending on the risk?

Introduce the risk thermometer and ask participants how they know when they are at 100°C risk, 80°C risk, 60°C risk - 0°C risk 1. In the first column, write down the situations at each of the following risks: 0°C, 20°C, 40°C,

60°C, 80°C, 100°C 2. In the second column get them to write the different types of action that can be taken at

different levels of risk

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Exercise 5: Skills Planning This exercise looks reviews each of the high-risk situations and looks at the skills that could help the person deal with that situation. It is important to emphasis that relapse prevention is not just about will-power, although determination to stop is necessary, but about the skills to deal with situations successfully so that they do not end up giving up all their life to stop using drugs and alcohol. This exercise also introduces the forth module of the group: Developing Skills.

What is the problem? For each high-risk situation there is a problem. This problem can be in the way someone thinks, feels or copes in the high-risk situation. Invite participants to look at the high-risk situations they have described and brainstorm what that problem might be.

E.g. High risk = Walking past a pub Problem = Thinking that I can’t cope without a drink High Risk = Being offered drugs Problem = Not feeling confident to say no

Fill in one example of the first column “Problem” on the Skills Planning table

For every problem there is a solution What are your goals for dealing with this problem?

Fill in one example of the second column “Goals”

What skills would help to cope with this problem Participant may need some guidance on how to describe the skills necessary

E.g. Saying “No” “Learning how to get help from people” “Learning how to tell people that I don’t use anymore”

Fill in one example of the third column “Skills Development”

What other things could help you reach your goals? Think about how other people or the clinical team could help.

Fill in one example of the last column

Participants can complete the other rows as part of their assignment.

Assignment: Meet with primary nurse / care co-ordinator.

Participants should complete their skills planning before the meeting with the primary nurse. Meet with primary nurses to: 1. Invite the participant to describe what has been gained so far. 2. To ask the participant to describe his high-risk situations, thoughts and moods 3. Review any recent relapses and see if they fit with the patient’s own understanding of high-risk

situations. 4. To review the skills development plan and see if the team can help to develop these skills outside the

group. 5. To arrange a meeting at the end of the group N.B. Ask one of the participants to bring a CD of the type of music that they used to listen to when they used drugs or alcohol to the next session.

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MODULE 4: DEVELOPING SKILLS

SESSION 14: Coping with Temptation and Cravings INTRODUCTION

This session starts off by looking at the how different cues can change our physical responses within our bodies. It goes on to use relaxation to cope with these effects on the body and increase our ability to cope with cravings. In the second half of the session, we develop a number of other key skills for coping with temptation and craving. Key Issues: 1. Temptation and cravings are the feeling provoked by external or internal cues which increases the

likelihood of using substances. Temptation is different from craving in that temptation can create a positive feeling whilst cravings are generally considered negative.

2. The experience of temptation or craving is not just about the physical addiction as explained in session 5, but also the ‘psychological’ addiction.

3. Coping with craving and temptation depends on a person’s “self-efficacy” in abstaining from using drugs. This is the individuals personal belief that he can overcome temptations and cravings without using drugs. Self-efficacy depends upon an individual’s previous experience, their emotional and cognitive resources available to them and contextual factors such as availability of drugs, social support and social attitudes.

4. Coping with temptation and cravings is something that substance users can do at certain times, but find it hard at others depending on their attitude, emotional state and social context.

5. There is no homework to review. Exercise 1: What are temptations or cravings?

This exercise examines feelings of temptation and looks in detail about the decision making process involved in relapse following temptation or cravings. The words temptation and craving can be used interchangeably.

What is temptation and what are cravings? 1. Elicit what participants think temptation and cravings are? 2. What are they and how do they effect us? 3. Is it physical or psychological? 4. What are people’s most recent experiences of craving or temptation and how did they deal with

it? Definition: Craving/Temptation are the internal thoughts and feelings of wanting, desiring or needing something believing that it will satisfy.

Session Objectives 1. Understand temptation and cravings

2. Differentiate different coping strategies including chemical coping, emotional coping and behavioural coping

3. Learn to identify cravings and temptation. 4. Develop the belief that individuals can cope with situations without using drugs.

5. Learn Urge surfing skills

6. Develop Relaxation skills

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It is important to distinguish between the feelings of cravings and the objects that make people crave.

What things do we, or can we crave? 1. What are all the different types of things that we crave?

E.g. Cigarettes, alcohol, drugs, sex, tenderness, food, relationships, love, 2. Is craving necessarily a response to chemicals? 3. Could you get cravings just from having thoughts about something without chemical withdrawal? 4. Do you ever get cravings from things that are not chemical?

Exercise 2: Developing skills for dealing with temptations and cravings

This exercise looks at other skills for coping with temptation and craving.

What do you do when you feel a craving for a substance that you’re trying to give up? 1. Elicit the types of feelings that individuals have when they are feeling temptations or cravings 2. Write these on the flipchart and discuss which are physical feelings, which are emotions and

which are thoughts (Code them Ph, E or Th) 3. Discuss which of the list are tolerable and which are unbearable. Think about which ones people

can ‘survive’, concluding that all cravings are ‘survivable’.

BREAK Exercise 3: What are my temptations and cravings

In this exercise, a drug session type of situation is set up to find out what participants find arousing and lead to temptation and craving.

Imitation drugs (e.g. salt for cocaine, herbs de province for cannabis, rubber for hash) A can of alcohol free larger for each member of the group

1. Participants should be seated in a circle around a low ‘coffee’ table with their handbooks 2. Present each substance one at a time, starting with the non-alcoholic beer and 3. After participants have been exposed to each of the substances for a few minutes, get them to rate

their levels of temptation

Cue 1 2 3 4 5 6 7 8 9 10

Alcohol

Cannabis Pipe

Cannabis

Foil

Paper wrap with white powder

Foil wrap with crystals

Tobacco tin

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Exercise 4: Heart Rate Monitoring This exercise aims to recreate a party type atmosphere to demonstrate the effects that this can have on an individual’s body (heart rate).

Portable CD player A heart rate machine

Skill learning steps: 1. Put the music on that someone has brought and recreate a party type scene. 2. Invite participants to pretend that they are using the imitation drugs. 3. Go round measuring the heart rate of each participant and make a note of it. Exercise 5: Urge Surfing Skills

Urge surfing is a form of self-hypnosis. It gets participants to imagine that drugs or alcohol do not exist and that they just need to let temptations and cravings wash over them without doing anything about it. Facilitators need to be creative in setting up this exercise as participants enter into the belief that drugs and alcohol no longer exist and that they can cope with cravings without them.

When you are thinking about drugs or alcohol, what can you say to yourself? 1. Leave the drug and alcohol paraphernalia on the table. 2. Play a relaxing CD and read the over the top of the background music: 3. Ask participants to close their eyes and sit comfortably in their chairs: uncross legs and place

arms by their side. If participants do not want to close their eyes, ask them to squint. 4. Remove the drug and alcohol paraphernalia during the reading passage. 5. Read the following passage slowly and meditatively:

The feelings of temptation and craving that you are experiencing are only in your mind. Let these

feelings wash under you. You are floating above these feelings of temptation and craving. These feelings are no longer inside you, but below you like a wave. These feelings will not drown you, they will make you stronger. They are carrying you to an island

where drugs and alcohol do not exist. Let these feelings of temptation and craving roll beneath you, like a wave. You have arrived in a world with no drugs or alcohol. There are no drugs and there is no alcohol

here. You are on dry land now. You can feel the warm sand on your back. The feelings of temptation and

craving have washed away. You do not want to drugs or alcohol. They do not exist. You feel warm and happy here. There is no more temptation or craving. You feel good about yourself. You have arrived where you want to be… Slowly open your eyes.

Exercise 6: Relaxation Skills

This exercise aims to demonstrate how relaxation can bring the body’s heart rate down and decrease the feelings of temptation.

Progressive Muscle Relaxation CD Copies of the Relaxation CD for each participant

Relaxation skill steps: 1. Ask all of the participants to put their drink away and put all the imitation drugs away 2. Ask everyone to sit upright in their chairs with their arms relaxed on the arm rest or by their side 3. Ask them to close their eyes, or if they are not comfortable with that, squinting their eyes 4. Play the Progressive muscle relaxation CD or read from a script

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Assignment: Diary of Coping with Temptation

Give each member of the group a copy of the relaxation CD. Get each person to think about one situation in the recent past when they were tempted and felt craving. Ask them to think how they could have used urge surfing or relaxation skills in these situations.

Ask each participant to record two or three situations of temptation and craving before the next session. Many of the participants will deny any situations of temptation and craving so this does not have to be about drugs or alcohol. It can be recording any situation in which they felt tempted to do something that they shouldn’t or feel a craving for something that they cannot have (e.g. food, people, sex)

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SESSION 15: Coping with Thoughts INTRODUCTION

This session builds on session 10 of the programme which looks at how automatic thoughts encourage substance use and looks at the types of thoughts in high-risk situations. It goes on to build on skills to help us cope with these thoughts in high-risk situations through the use of self-statements, thought replacement and thought distraction. Key Issues: 1. The types of beliefs that people hold generally about substance use is different from the type of

automatic thoughts that may be made in high-risk situations. These thoughts may not reflect someone’s general beliefs, but may rationalise the use of drugs and alcohol in that situation.

2. There is an overlap between the four skills being developed in this session: Self statements, thought distraction and thought replacement. However, some may find the different approaches to high-risk thoughts useful.

3. The self-statements should be recorded in participants’ handbooks so that these can be used on the emergency cards that will be given out in session 24.

Review Homework:

Since the last session, what things have you been tempted to do or felt cravings for?

1. If participants deny any temptation or craving then joke about how they must have everything. 2. Think about why they might have felt temptation or craving at that time or in that situation. 3. Ask if they have used the relaxation CD or the urge surfing skill. 4. Review temptation and craving diaries and reinforce any completion.

Exercise 1: How can automatic thoughts lead us to a High Risk Situation

We have already introduced the idea of automatic thoughts in session 10 and looked at the different types of thoughts (e.g. justification, minimisation etc.). This exercise reviews automatic thoughts in high-risk situations.

What happens to our thoughts when we feel temptation or cravings? Invite participants to think about their last high-risk situation and reflect on what is happening in their minds when they are tempted. Elicit participants’ personal thoughts in high-risk situations

Our thoughts try and rationalise the use drugs or alcohol to satisfy these cravings. They do this

by either: 1. Making the use of drugs and alcohol seem less bad (justification, minimisation, normalisation,

denial). E.g. “Drugs are not a problem, everyone uses them”

“One joint never hurt anyone” 2. Changing our attitudes to using drugs or alcohol. E.g. “I don’t care if I use drugs or alcohol. It’s everyone else that thinks that they’re wrong” Review participants’ thoughts, and decide which type of rationalisation they are.

Session Objectives 1. Understand the role of thoughts in our high-risk situations

2. Develop Self-Statements to cope with high-risk thoughts and situations.

3. Practice thought distraction, thought distraction and mindfulness skill

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Exercise 2: Self-statements Skill This exercise aims to identify the key self-statements that help a person remain abstinent from drugs or alcohol. It is important that these statements are meaningful to the individual rather than just the typical statements that don’t hold such great meaning. These statements can be worked out from the Advantages and Disadvantages exercise in session 3. Participants may want to make over-generalised or idealised statements that do not relate to their specific situation (e.g. “I must be strong”. “God will help”). Try and relate these to the person’s own final goals and current objectives and to their plans for substance use.

What could you say to yourself if you were in a high-risk situation to help you not use drugs or alcohol? Ask the group to turn in their handbooks to the “Advantages and Disadvantages” of using or not using drugs or alcohol. From the section on Advantages of not using drugs or alcohol or Disadvantages of using drugs or alcohol, ask participants to make a short positive self-statement: These should 1. Remind them of their goals and ambitions

E.g. If I don’t use drugs or alcohol I can get up for work easily 2. Remind them of the people that they want to make happy

E.g. If I don’t use drugs or alcohol, I can spend the money on my children 3. Make them think about the consequences of using drugs or alcohol

E.g. If I use drugs or alcohol, I’ll only end up back in hospital. 4. Make them think about alternatives to drugs and alcohol

E.g. I can cope with life without using drugs and alcohol

Rules for Self statements 1. Self-statements should help you think about your goals and ambitions 2. Self-statements should reflect a positive outcome from not using drugs or alcohol 3. Self-Statements should help to think about the negative consequences of using drugs or

alcohol.

Ask each participant to write down one or two of their most helpful self-statements in their handbook. We will use these self-statements in developing an emergency card later in the manual.

In pairs (3 minute exercise):

Participant #1 makes statements to participant #2 encouraging the use of drugs or alcohol. #2 responds using his self-statements.

BREAK Exercise 3: Thought Distraction Skill

This exercise develops a new skill called thought distraction. It attempts to recreate the internal voices that may tempt individuals to use drugs and alcohol and practices distracting from this internal voice.

When you are thinking about drugs or alcohol, what sort of things could you say to yourself to distract yourself? Elicit the types of statements that can be used to cope with temptation. These can be worked out from the advantages

In pairs (5 minute exercise):

Participant #1 stands behind participant #2 who is sitting down. #1 whispers temptations to use drugs quietly into #2’s ear #2 speaks out loud to try and distract themselves from the temptation voice

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Exercise 4: Thought Replacement Skill

This exercise is different from thought replacement in that the person does not necessarily respond to their tempting thoughts but thinks about a story that does not include references to drugs or alcohol.

Have you ever used thoughts, day dreams or fantasies to distract from using drugs or alcohol? Ask participants if they use day dreams or fantasies that do not involve using substances to distract themselves from cravings. Get one participant to start a story and go round the room continuing on the story. If reference is made to substances or cues that may increase cravings get the person to change the story.

How could you use this skill in high-risk situations?

Ask participants if they think that they could use this skill when they are at high risk and think about some of the practicalities of using this without seeming ‘strange’ to other people.

Exercise 5: Mindfulness Skill

This exercise differs again from the previous two. It uses the concept of mindfulness to focus thoughts away from drugs or alcohol. Mindfulness is where we fill our thoughts with a particular person, place or object to the exclusion of all else. This exercise practices with a sultana. It aims to fill the person’s thoughts until nothing else can be thought about, by going over every detail of the sultana ‘experience’. The instructions can be embellished to make them longer r depending on time and the group.

Packet of sultanas

We are now going to practice mindfulness Give a rational for the exercise before starting

1. Ask everybody to sit comfortably with their legs uncrossed. 2. Give each person a raison or sultana. 3. Read the following in a slow meditative voice:

Hold the sultana between your fingers. Try to focus your attention on the sultana without holding on to any particular thoughts, but

without pushing thoughts away. Let the experiences of the sultana go through you mind and slip right out. Become alert to every thought and sensation about the sultana that comes into your mind. Look at the surface of the sultana, its colour and how the light reflects from it. Feel the texture of the surface of the sultana. How does it feel when you turn it between your fingers? Think about how soft or hard the sultana is. Place the sultana in your mouth and before chewing, experience the texture and feeling in your

mouth. Feel how your mouth reacts and starts to produce saliva. Start to slowly chew the sultana and as it breaks, how the texture feels between your teeth. Taste the sultana as you chew. Feel the sultana as it falls to the back of your throat, being swallowed and going down Do not hold on to any of these experiences but let them flow right through your mind. Do not separate yourself from the experience, but let yourself become one with it, like dancing to

music.

How could you use this skill in high-risk situations? Ask participants if they think that they could use this skill when they are at high risk and think about some of the practicalities of using this without seeming ‘strange’ to other people.

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Assignment: Diary of Coping with Thoughts

Ask participants to continue to monitor their high-risk situations in which they were feeling tempted or carving. For each situation:

Monitor the types of automatic thoughts Practice using the thinking skills

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SESSION 16: Coping with Moods and Emotions INTRODUCTION

This session thinks about the role of emotions in placing us at high-risk of using drugs or alcohol. It looks at which are our high-risk emotions and how do we recognise them. It goes on to think about how we can ‘set-up’ high-risk moods to justify our use of drugs or alcohol. Key Issues: 1. At this stage in the course, responsibility is shifted from the facilitator to individual participants to

provide the content of the sessions. The ability of participants to take this responsibility can be an indicator of their internalisation of the course so far, and their motivation to change their substance use problems.

2. Participants are increasing required to disclose personal issues around situations that they found difficult. This is done through use of the Cravings Diary, and personal accounts of events.

3. The individual’s own coping strategies should always be explored prior to suggesting coping skills that have been covered in modules 1 and 2.

Review Homework

Have there been any times when you were tempted to do something or felt any craving to

do something? Review the Thinking Skills Diary If individuals have not completed their diary, ask them to think about situations in which they have felt tempted or felt any cravings for anything. Did participants use the skills developed so far?

Review the usefulness of all the skills developed so far in dealing with those situations. 1. Urge Surfing 2. Relaxation 3. Self-statements 4. Thought distraction 5. Thought replacement 6. Mindfulness

Exercise 1: Recognising emotional states.

The purpose of this exercise is to help participants recognise emotional states at times when they have been most vulnerable to relapse. This is done by identifying recent high-risk situations and exploring with each participant what they think was going on with them at that time. It goes on to introduce the concept of high-risk emotions. Many emotions can be associated with the use of drugs or alcohol. Usually it is the intensity of the emotion that places at high-risk of using drugs or alcohol: either extremely good moods or extremely bad moods.

Session Objectives 1. Review situations when participants have been tempted to use substances and

the use of the skills developed so far.

2. Introduce the idea that emotions can place use at high risk of using drugs or alcohol.

3. Find out which are our own personal high-risk emotions

4. Look at how we can ‘set-up’ emotions to justify our use of drugs or alcohol

5. Look at ways of coping with high and low emotions.

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How are you all feeling right now? 1. Invite participants to spend a couple of minutes in silence ‘listening’ to their emotions and how

this feels. 2. Go into detail about their actual current emotional experience. 3. Are there good feeling or bad feeling? Or both? 4. Elicit words that describe these emotions and write them on the flip chart. 5. How intense is the feeling? Rate each of the emotions on the flipchart 1-10. (10 is most)

How easy is it to know how we are feeling?

Hold a discussion on the difficulties of recognising our emotions.

What are the moods that put us at high-risk of using drugs or alcohol? 1. Think of all possible moods and add to those in exercise 1: E.g. Depressed, Anxious, Angry, Guilty, Ashamed, Sad, Embarrassed, Excited, Frightened, Irritated, Insecure,

Proud, Annoyed, Panicky, Frustrated, Nervous, Disgusted, Hurt, Cheerful, Disappointed, Enraged, Scared, Happy, Loving, Humiliated

2. Using the list of moods elicited in Exercise 1 mark with a or which one of the emotions can be associated with the use of drugs or alcohol.

3. Would participants always be at risk if they were in this state? 4. Is it something about the intensity of the emotion that places the individual at risk of using drugs

or alcohol?

It is usually the extremes of good moods or bad moods that put people at risk of using drugs or alcohol.

Exercise 2: Which moods put us at high-risk of using drugs and alcohol?

Evidence has shown that people who are better able to recognise and assess moods and challenge the associated automatic thoughts are less likely to relapse in mood. This exercise aims to introduce participants to each of these three factors in relation to their typical high-risk moods.

What are the negative moods that put you at risk of using drugs or alcohol? Discuss the types of negative emotions that can contribute to using drugs or alcohol. This can include depression, anxiety, or anger.

In your handbook, complete the first two columns:

1. Describe the typical moods or emotions that put you at high-risk of using drugs or alcohol (column 2)

2. Rank the moods or emotions in order of risk (1-10) (column 1)

How do you recognise when you are feeling in a high-risk mood? It is often our thoughts or our actions that tell us when we are feeling in a high-risk mood.

E.g. Start to think that I don’t care or nothing matters any more. Feel helpless and cannot change anything

Describe how you recognise when you are in these typical high-risk moods (column 3).

What can you do in these situations? First brainstorm some of the actions that can be taken when in high-risk moods:

E.g. Go out of the house and meet with other people. Take my mind off things by doing something else.

Describe what you could do when you are in these typical high-risk moods (column 4). How

effective have these actions been in the past, or how effective do you think they would be

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Exercise 3: Not putting ourselves in situations that cause high-risk moods? In this exercise, the aim is for individuals to explore how moods can create a justification for using substances. In the same way that we can put ourselves in a high-risk situation through unconscious actions, we can put ourselves at risk through unconsciously creating moods. Creating either of these moods can place us at high-risk of using drugs or alcohol.

Have you ever not wanted to go to school/work and pretended to be ill so much that you actually believed you were ill?

Discuss how easy it is to fake symptoms of being ill. Ringing the boss whilst holding your nose…

Have you ever put yourself in a mood that might justify the use of drugs or alcohol? Invite participants to think how this might occur. E.g. Feeling down and sorry for yourself. Starting an argument that will lead to feeling bad.

It is important to be aware when we want to use drugs or alcohol and we put ourselves in a certain mood that will justify our use of drugs or alcohol. BREAK Exercise 4: What can we do about our emotions?

This exercise looks at ways of dealing with feelings and emotions that may lead to drug and alcohol use. It elicits people’s existing ways of coping and suggests a number of ways of managing emotions that participants may already be doing, but may reinforce their ability to cope with emotional states other than by using drugs or alcohol. Each of the methods are described in the handbook.

What can you do in these situations? First brainstorm some of the actions that can be taken when in high-risk moods:

E.g. Go out of the house and meet with other people. Take my mind off things by doing something else.

Describe what you could do when you are in these typical high-risk moods (column 4). How

effective have these actions been in the past, or how effective do you think they would be

There are a number of other ways we are going to try to help with emotions 1. Letting Go of Emotions 2. Changing Emotions by Acting in the opposite way 3. Distraction 4. Self-Comfort 5. Improve the moment

Invite each of the participants to think about their current feelings in going though the 5 ways of coping with emotions. Whilst presenting each method, ask participants to contribute other suggestions that would help them cope with their emotions and how effective they think each method would be. Each presentation should be experiential and, depending on the feelings of the group, they can be tried out at the time.

OHP Letting Go of Emotions (also in handbook) Try the following four steps to letting go of emotional problems. Go through the steps and thinking about their particular emotion at the time. 1. Observing your emotions 2. Experiencing your emotions 3. Separating ourselves from our emotions

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4. Accepting our emotions

OHP Acting in the Opposite Way After each emotion ask how else we could act in the opposite way to cope with the emotion.

OHP Distraction Ask participants which distraction they already do and which emotions it helps with. Go through the OHP list of distraction techniques.

OHP Self-Comfort Ask participants if there is anything else that they can do to comfort themselves (other than using drugs or alcohol).

OHP Improve the Moment

Prayer does not relate to any specific religion and all participants can appeal to a higher being or self to improve the moment.

Try out some of the imagery techniques getting feedback (humour is essential). Get any other suggestions on how to improve the moment. Assignment: Diary of coping with moods

Continue to keep diary of high-risk situations, this time recording the moods and associated thoughts. The focus of this assignment should be on coping with the moods as well as their associated thoughts. Encourage participants to try and use some of the skills learned in today’s session to help them manage their moods. Practice one past situation in the group before setting the assignment.

Complete diary on coping with moods.

Also ask participants to start reading the information about symptoms of Schizophrenia and Bi-polar disorder in the handbook under session 17.

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Letting Go of Our Emotions

OBSERVE YOUR EMOTIONS • Become aware of your emotions • Note that it is there • Step back from this emotion and see it as if it belonged to

someone else. • Separate yourself from this emotional state and be yourself

EXPERIENCE YOUR EMOTIONS • Feel the emotion as a wave washing backwards and forwards • Do not try and stop or block the emotion • Do not try and get rid of the emotion or pretend that it is not

there • Try not to hold on to the emotion and just let it come and go • Do not try and make it bigger and smaller YOU ARE NOT YOUR EMOTION • You do not have to do anything about your emotions • You do not have to act or behave differently • Your emotions will come and go but you will still be there • You do not have to block out the emotion using drugs or

alcohol ACCEPT YOUR EMOTIONS • Do not deny that you are feeling any particular way • Your emotions are part of our experience

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Acting in the Opposite Way to Change Emotions OPPOSITE OF FEAR • Approach situations, people or activities that are making you afraid • Do this by making small confident steps towards what you are

worried about. • Gain a sense of CONTROL over the fear • Do what you are afraid of doing OVER and OVER and OVER OPPOSITE OF ANGER • Think something nice about the thing that is making you angry rather

than thinking angry thoughts • Say something nice to the person that might be making you angry

rather than • Let your face relax and smile rather than scowl. OPPOSITE OF SADNESS OR DEPRESSION • Don’t give in to the sadness, get active and do something • Do things that make you feel good about yourself • Say things to yourself that make you feel more confident • Raise a half-smile, even if at first you don’t feel like it OPPOSITE OF BOREDOM • Find out what are all the things you can do at that time • Give yourself many things to do before a certain time. • Do those things that you have been putting off for a long time. OPPOSITE OF GUILT OR SHAME • Rather than avoiding the situation, face the mistake

• Say sorry for the mistake • Make things better (do something nice for the person)

• Rather than avoiding thinking about the mistake • Think about what you have done • Accept the consequences of your actions • Commit to not making that mistake again

• Let the guilt or shame go rather than holding on to it

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Using Distraction to Manage Emotions

USE ACTIVITIES TO DISTRACT • Use exercises and go for a walk • Think of a hobby and something to get interested in. • Do the cleaning and feel good about doing it afterwards • Go to an event • Read a book or magazine • Organise a sport or play computer games GETTING INVOLVED • Get into something that occupies your thoughts • Get involved in doing something with someone else • Make something for someone USE THOUGHTS TO DISTRACT • Think about something else • Focus your mind on something (mindfulness) • Work out some puzzles or crosswords Count to 10, or observe things around you in great detail USE SENSATIONS TO DISTRACT • Squeeze a ball • Hold ice in your hand • Flick an elastic band on your wrist

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Using Self-Comfort to Manage Emotions

VISION • Put something beautiful in your surroundings • Look at nature around you • Do something to make yourself look better (e.g. change your

hair) • Look at the stars • Go and see something beautiful (e.g. art gallery) HEARING • Listen closely to something beautiful (e.g. birdsong) • Learn to play an instrument • Listen to a beautiful calming piece of music SMELL • Use your favourite after-shave or lotion • Go into the woods to smell the nature • Smell flowers or bushes • Put some nice scents in your room TASTE • Eat something nice that you haven’t had for a while • Eat your favourite food and savour the taste • Try something new TOUCH • Have a bubble bath • Soak your feet • Make yourself really comfortable • Put on some clothes that feel nice • Touch different fabrics (e.g. silk, soft wool, fur)

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Improving the moment

IMAGERY • Imagine a Relaxing Scene • Describe a fantasy to yourself that makes you feel better MEANING • Look for the positives in the moment • Think about some of the good things that can come out of

difficult situations. PRAYER • Open your heart to God or the good side of yourself • Ask for strength to accept the difficulties in life and for peace

of mind RELAXATION • Relax your mind and relax your body • Become aware of all the tension inside yourself and let go of

it • Complete progressive muscle relaxation

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SESSION 17: Coping with Symptoms and Side Effects INTRODUCTION

This session looks at the relationship between symptoms, side effects and the use of drugs and alcohol. Symptoms and side-effects are extremely distressing and people use alcohol or drugs to manage this distress. Some illicit drugs can actually help with certain side effects. However, both alcohol and drugs can also make the symptoms worse and lead to increased medication which can increase symptoms and side-effects. This leads to a vicious circle of mental health problems and drug and alcohol use. This session goes on to look at how to cope with symptoms or side effects without using drugs or alcohol and not getting into this vicious circle. Key Issues: 1. Whilst substances, particularly drugs can increase the risk of mental health problems, it is also

possible that symptoms of mental illness can also increase the risk of using drugs or alcohol. 2. Many of the approaches to dealing with symptoms will be the same as dealing with moods and

thoughts dealt with in the previous sessions. It is always worth reflecting on these approaches in talking about how to cope with symptoms and side effects.

3. You will need a TV and/or video for one of these exercises. Review Homework: Monitoring moods

It is important that all members of the group are regularly monitoring their thoughts and moods as well as managing the high-risk thoughts and moods.

Did anybody recognise any difficult moods that made them more tempted to use drink or drugs? How did you cope with those feelings?

Review any situations / moods that may have been difficult. Ask participants if they can remember any of the strategies for dealing with their moods (they can use their handbooks to remind themselves) Ask each person to review one situation from their diary, how they handled it and what was the outcome.

Session Objectives 1. Look at how symptoms and side-effects can place us at high-risk of using drugs

and alcohol.

2. Understand what are our key symptoms that lead to using drugs or alcohol. 3. Remind ourselves of the vicious circle between symptoms, medication, side-

effects, and drug or alcohol use. 4. Look at alternative ways of coping with symptoms or side effects other than using

drugs or alcohol.

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Exercise 1: How do we Recognise Symptoms? This is a relatively quick exercise that aims to normalise the experience of mental health problems by looking at famous people who have experienced symptoms of mental health problem. It is important to use appropriate language in which participants do not feel that they are being labled. Depending on the group, mental health difficulties should be used instead of mental illness, and experiences can be used instead of symptoms. Participants are asked to describe their own experiences of symptoms of mental health problems. Some participants may not recognise or wish to disclose that they have (or have had) a mental health problem. It is possible for them to describe experiences in the 3rd person – what other’s might experience.

At some time, nearly all people have difficulties in their mental health? Who are the famous people in history with mental health problems? Fact: MIND estimates that 25% of the population suffer from mental health problems and that most people have had some difficulties at some point in their life. Elicit people that they know that have suffered from mental health problems? Give some examples:

1. John Nash, Nobel Laureate: Suffered from schizophrenia 2. Jason McLean, artist: Suffered from schizophrenia 3. Winston Churchill: Prime Minister during the war had manic depression. 4. Ludwig Beethoven: The brilliant musician experienced manic depression. 5. Abraham Lincoln: The 16th president of America, suffered from severe, incapacitating and

occasionally suicidal depressions

What type of things do people experience when they are having mental health problems? Participants do not have to describe themselves during a psychotic relapse, but it is important that they are able to think about themselves when they are not mentally well. It is possible to give an example of what people are like when they are like when they are stressed, but it is important not to talk only about stress reactions.

Experiences Behaviours Thoughts e.g. Getting nervous around people Avoiding People “People are talking about me” Getting confused Talking very fast “It’s all too much” Not sleeping or sleeping too much Staying in bed all day “It’s not worth getting up” Getting more angry than usual Shouting at friends “Everybody’s against me”

What are your experiences when you are not feeling your best and when your mental health starts to deteriorate?

Exercise 2: Do drugs and alcohol help to manage symptoms?

In this exercise, participants are asked to describe their own experiences of symptoms and side effects. These need to be dealt with separately as people are often better at recognising the difficulties of medication than the difficult experiences associated with mental health problems. Some participants may not recognise or wish to disclose that they have a mental health problem. It is possible for them to describe experiences in the 3rd person – what other’s might experience. It is also important to state that most people have mental health problems at some time in their life, including depression or anxiety.

Could drugs or alcohol be used to cope with any of these feelings? Discuss the use of drugs or alcohol as a way of compensating (self-medicating) for symptoms. e.g. Feeling down => taking drink to make you happy or numb the feeling Feeling tired => Using drugs to make you feel more awake On the flip-chart, identify which of the experiences, behaviours or thoughts may lead to drug or

alcohol use by placing a or next to them.

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Using drugs or alcohol may help with the symptom, but do they may also increase mental health problems.

There are a number of reasons for this: 1. Drugs and alcohol will only help with side effects in the short-term and will increase your

vulnerability to mental health problems. 2. You will need to use increasing amounts of drugs or alcohol to achieve the same effect in

managing symptoms. This increase in use will affect your mental health. 3. Drugs and alcohol also have side effects that can reduce your ability to manage your symptoms. 4. Drugs and alcohol counteract the effects of medication and can then lead to

Exercise 3: How can medication help us with symptoms of mental illness?

This exercise gives a brief overview of the way in which medication works in order to explain the interaction between drugs, alcohol and medication. It also aims to share some of the participant’s experiences in using medication. There are likely to be negative attitudes towards medication as well as some positive attitudes. It is important to distinguish between managing symptoms and side effects.

How does medication work? Medications work in a similar ways to all drugs in that they effect the communication of neurotransmitters between cells in the brain. It does this by either increasing their production (increasing the rate at which they are received by the next cell) or reducing the rate at which they are taken back by the previous cell (re-uptake).

What are the different types of medication and their possible benefits? Go through all the different types of medication and discuss their benefits (also in handbook).

What could be the pros and cons of using medication? Discuss people’s different experiences of using medication.

Write down some pros and cons of using medication for you.

BREAK Exercise 4: Skills for coping with symptoms

This exercise looks at some psychological approaches to coping with symptoms. These exercises focus on evaluating the experience and mental control. It is important to emphasise that doing nothing (burying your head in the sand) will not help. These exercises can be practices during the session.

We are now going to practice a number of ways of dealing with symptoms of mental health problems.

1 Distraction “Distraction can be used with a number of symptoms of mental illness. It works by taking your attention away from the symptom that my be causing distress or uncertainty, and focusing the mind on something else” Exercise:

1. Put one participant in front of a TV programme (preferably an action packed film). 2. Ask them to describe their favourite car, place, or someone they’ve met. 3. Ask if they had any difficulty in distracting themselves from the TV. 4. Identify symptoms which participants use distraction coping. 5. When is distraction not appropriate? (When it’s avoidance!)

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2 Grounding / Normalising “Grounding or normalising described the process of making your experience real. It works by focusing on the things that you are certain about, rather than the things that you are not sure about. You can do this in a number of different ways, but we are going to practice by describing the immediate environment” Exercise (this exercise should be practiced like a game):

1. Invite one participant to describe everything in their immediate environment that is based on fact rather than opinion without repeating anything (This should include objective rather than subjective experience: e.g. the bin is on the floor not the window is dirty or the plant is beautiful).

2. Ask other participants to say when they do not agree with what the person is saying 3. Go round the group one by one describing things without repetition and without making an

opinion. 4. Reflect on how difficult it can be to describe things without making an opinion 5. Discuss which symptoms this exercise could be helpful with.

3 Focussing/Concentration “This exercise is designed to take the focus away from some thoughts and place them onto others. It works a little like distraction, but rather than taking the mind away onto many other things, it narrows your thoughts onto one thing. This can be focusing the mind onto something nice such as an image or person, or something positive, like a self-statement” Exercise:

1. Invite one person to sit on a chair with a second person behind them (so that they cannot see them directly).

2. Ask the second person to whisper things to the person sitting down that will make them paranoid or worried.

3. Ask the first person sitting down to describe out loud a beautiful image in their mind or something positive.

4. Try this with a number of other members of the group. 5. Discuss the type of experiences, thoughts or feelings (from the flipchart) when this might be

helpful.

4 Reality Testing “Reality testing is helpful to get a shared understanding of what is going on. This can be done in asking other people what they think is happening. It does not have to be a direct disclosure of what you are thinking but some question that will help you to test your reality” Exercise:

1. Give each participant one of the following examples written on a small piece of paper that only they are allowed to look at: “You think that the person at the opposite end of the room is looking at you and thinking bad things about you. You are not sure and need to check your reality” “You can feel the floor starting to move but you are not sure and need to check this reality” “You really believe that you are the greatest singer of all time. You are not sure, check your reality” “You think you can fly out of the window and get away, but you need to check this reality” “You can hear someone saying your name but you are not sure. You need to check your reality”

2. Ask each person one by one to chose someone in the room who is likely to be the best person to help them check their reality. They should not use direct questions (otherise they may feel foolish) but ask an indirect question to an impression about their reality.

3. Discuss the difficulty in checking out strange thoughts or feelings. 4. Discuss the importance of choosing the right person to ask without causing offence or

embarrassment.

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Exercise 5: What are side effects and how can we cope with them

This exercise explores the side effects of medication and how drugs and alcohol can be used to manage these problems. It looks at whether drug or alcohol use is a good way of managing side effects in the short-term or long-term.

What are side effects? “In basic terms, side effects are the unwanted result of taking a medication which not only does the thing that it is supposed to do, but acts on other parts of the body as well. Psychiatric medication affects the neurotransmitters in the brain, which are used for more than one function. This means that medication can also cause side effects. For example, the desired effect may be to cure depression, but some antidepressants can give you headaches or a dry mouth.”

“There is some information about side effects in your handbook to read later if you want more explanation.”

What side effects have your experienced?

Elicit side effects: E.g. Dry Mouth

Invite participants to fill in column 1 and 2 in their handbook: Medication and Side Effects.

Can other medication help with side effects? The side effects of one medication can help to counter-balance the side effects of another

medication. E.g. One medication gives you a dry mouth – another medication makes you salivate. Elicit the types of side-effect medication that participants use to help them with their side effects.

What other activities help with side effects? The group can discuss ways in which they cope with the side effects of taking medication. If the group does not offer any suggestions, invite them to try/experiment with some activities that may help.

E.g. Feeling tired => Go out for a walk Leg tremors => do some stretching Vision blurred => focus on doing some drawing

Fill in column 3: Medication and Side Effects for the things that they do when they get side effects including medicine or activities.

Assignment: Diary of Coping with Symptoms and Side Effects

This assignment aims to get participants to monitor their experience and thoughts, rather than letting them escalate, try and do something about them.

Complete the symptom diary.

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John Nash, Nobel Laureate Had schizophrenia

Jason McLean, Artist Had schizophrenia

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Medication Category Possible benefits

Antidepressants

Can reduce the symptoms of depression, including low mood, poor appetite, sleep problems, low energy and difficulty concentrating. They can also be effective in treating anxiety disorders.

Mood stabilisers Can help reduce extremes of moods, including mania and depression

Antipsychotic medications

Can reduce the symptoms of psychosis, including hallucinations, delusions, and disorganised speech or behaviour.

Anti-anxiety and sedative medications

Can reduce anxiety, feeling over-stimulated, and difficulty sleeping

Session 17 OHP: Medication

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SESSION 18: Coping with Anger and Arguments INTRODUCTION

This session looks at how arguments can place us at high-risk of using drugs or alcohol. It looks at how we can get into arguments and manage them better. It does this by developing better assertion skills so that we can use arguments to express ourselves without feeling that we have been put-down and without putting other people down. Rather than arguments being stressful and destructive, they can be our opportunity to say how we feel and sort problems out, rather than create more arguments. Key Issues: 1. Arguments and anger can be one of the key triggers to using drugs and alcohol. 2. Anger can be expressed or not expressed. Expressed anger can lead to difficulties if it is not

managed well. Equally, non-expressed anger can be internalised and lead to drug and alcohol use. 3. Anger can be managed in a way that can respect your rights as well as other people’s rights, a win-

win situation. Review Homework

This exercise reviews whether people have had any symptoms or side effects since the last session and which techniques they used to manage them. If participants have not had any symptoms since the last session, focus on the side effects and how these were managed.

Has anyone had any difficult feelings or symptoms or side effects? Review the coping strategies. Get some feedback on the effectiveness of the techniques that were developed in the last session.

Exercise 1: How does anger affect us?

This quick demonstration and discussion exercise looks at how our bodies respond to anger and stress if we do not manage these problems. It also looks at the problems that can arise from coping with anger by using drugs and alcohol. You will need a bottle of fizzy drink in order to demonstrate how anger can build up.

What happens if we do not manage anger? 1. Show the bottle of coke saying “Imagine this is you”. 2. Shake the bottle of coke saying, “This is what happens when you get stressed. If you do not

manage your stress well the pressure will build up and build up.” 3. Ask participants: “What would happen if you suddenly took the top off? It would explode! Life gets

very messy!” 4. If we can release this stress and anger gently then we can let it out without any problem. Anger

management does not mean shutting the lid on your anger or holding it in

Session Objectives 1. To identify the type of situations which make us angry.

2. To think about how arguments and anger can lead to substance use.

3. To develop assertion skills for dealing with arguments and anger that will not leave people feeling guilty or upset.

4. To practice assertion skills using rehearsal and role-plays.

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What would happen to this anger if we used drugs and alcohol? Elicit people’s ideas about how drugs and alcohol can work in this situation. E.g. “Cannabis calms me down and helps me relax” “Having a drink stops me from getting angry”

Emphasise that if you use drugs and alcohol to cope with stress or anger, then the problem has not gone away, but that the feelings have been suppressed. Using drugs and alcohol is a bit like screwing the lid on the fizzy drink a bit harder. It should also be pointed out that using drugs and alcohol can put stress on the body as works harder to eliminate the chemicals in the body.

Exercise 2: What makes us angry?

This exercise aims to explore some of the activating events (antecedents) that can precede angry events. It aims to draw out some common themes in angry situations in order to help participants generalise these situations. It is important to empathise with the difficulties in dealing with these situations without condoning the use of violence to cope with them.

What situations make us angry? Get a list of the types of situations that can make participants angry. Interpret these within some themes that can generalise to other situations.

E.g. Being told what to do Dealing with Authority Girlfriend nagging Feeling put down Being told you can’t go out Being blocked

Develop a general understanding of the types of difficulties and empathise how difficult these situations are to handle.

Exercise 3: What do we think in angry situations?

This exercise introduces the idea of automatic thoughts about situations that can increase feelings of anger. It also looks at alternative thoughts that are less likely to make us angry and promotes to feeling of choice to let ourselves become angry.

How do these difficult situations make us think and feel? Based on the situations (antecedents: A) already on the flipchart write people’s beliefs (B) about these situations on an adjacent flipchart and how their beliefs about a situation may make them react (C).

Is it possible to change our thoughts about a situation so that we do not become as angry?

1. Elicit some ideas about choice in situations to think in many different ways about a situation rather than just thinking automatic thoughts about typical problems.

2. Use some of the situations given by participants to challenge their automatic thoughts about a situation or use the examples given here.

3. Try and find alternatives to the automatic thoughts and see if these make the person less angry about the situation.

Write down one or two situations using the ABC model.

BREAK

A: Situations Being told what to do Girlfriend nagging Being told you can’t go out

B: Beliefs C: Responses He’s just doing for his own pleasure I’m going to get him back She’s always putting me down I’ll put her down He thinks he’s god I’ll show him he isn’t…

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Exercise 4: Assertiveness skills This exercise aims to teach basic assertion skills and simple methods coping with interpersonal situations that make people angry. It develops the idea of assertion skills as a means of protecting our own rights in a situation without taking away someone else’s rights.

What is assertion? What does is mean to be assertive? What are assertive people like? What makes people communicate in different ways? Can you think of anybody you know/famous who is good at dealing with problems? Are people who cope well with arguments more likely to be successful in life?

What are the different styles of assertion?

Aggressive Over- Assertive Assertive Passive/ Manipulative

Intimidating Too Strong Forceful Making point clearly politely directly not making point quiet giving in

What assertion styles are being used in this situation?

Facilitators demonstrate three assertion styles: Aggressive, Passive, and Assertive. Get feedback from the group as to which style is was and how the scenario looked or felt.

Scenario: A customer is returning to an electrical shop to return a faulty video camera that he has bought. He approaches the sales person in a three different ways.

Facilitators role-plays the Invite a participant to pretend to be a sales person in an electrical shop.

Tip for being assertive (also in handbook) 1. Think about why you are annoyed and what needs to change. 2. Remind yourself that you can deal with this situation without getting angry. 3. State what the problem is in your opinion. Use the expression: “I feel that…” (people cannot

disagree with your feelings”). E.g. “I feel that you are being rude when you talk to me like that…”

4. State how the problem effects you. E.g. “I get annoyed when you talk to me like that…”

5. State what you think the solution is. E.g. “I think that we would get on better if you could talk to me without being rude…”

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Exercise 5: Role-Play Assertiveness skills This exercise gives all participants the opportunity to deal with an angry situation using problem solving and assertion skills. The scenarios are taken from the angry situations in exercise two. These scenarios need to be simplified so that they can be practised in the group and their outcomes evaluated. Some reflection on the individual’s thoughts about the situation should be mentioned during or in setting up the role-play to remind participants the importance of automatic thoughts.

Participants role-play one scenario that has made them angry in the past Other participants or facilitators should be used as co-actors precipitating the situation.

Ask other participants to be observers evaluating whether the actor used the tips for assertiveness in coping with that situation. They can check the scenario against the tips for assertion in their handbook.

Assignment: Diary of Assertions Skills

This diary records some of the situations that have made people angry during the week and aims to use the two skills that have been developed in today’s session: Challenging Angry Thoughts and Assertion skills.

Identify any situations that have made people feel annoyed or irritated between now and the next session.

Write down How Risky that situation was, and how much it would be likely to put them at risk of using drugs or alcohol if they were in the community.

Write down the automatic thought about the situation and how angry this thought made them feel Write down the alternative thoughts about the situation and how angry these alternative thoughts

make them feel. Write down the outcome of the situation and how well they felt that it turned out 10 = Very Good E.g. Resolved problems without walking away or getting angry 0 = Very Bad E.g. became angry and hit the man

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Tips for being Assertive…

1. Prepare yourself to deal with a difficult situation but remind yourself that you can do this without becoming angry or aggressive.

2. Think about why you are annoyed and what needs to change. State what the problem is in your opinion. E.g. “I think that you are being rude when you talk to me like that…”

3. State how you feel about the problem and how this effects you (people cannot disagree with your feelings). E.g. “I feel really annoyed when you talk to me like that…”

4. State what, in your opinion, you think is the solution. E.g. “We would get on better if you could talk to me without being rude..”

Session 18 OHP: Tips for assertion

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SESSION 19: Coping with Persuasion and Saying “No” INTRODUCTION

This session looks at the important area of saying no to drugs and alcohol when offered by acquaintances, friends or family. This is important as people frequently feel that being offered drugs or alcohol is one of their high-risk situations. Firstly, it looks at these difficult situations and what we think people think of us when we say “no”. It goes on to look at the outcome of different assertion styles and how to develop an assertion style that can help to maintain abstinence but also their friendships. Key Issues: 1. Substance use is often part of a more general lifestyle. Social gatherings are based on the use of

substances. In these situations people are often offered substances in order to join in the social occasion, or they feel obliged to use to fit into the social group or event.

2. It is often difficult for individuals to say no to substances as they feel that this may draw attention to the fact that they may have had problematic substance use in the past or that they have had a mental health problems in the past.

3. It is important to develop assertion skills that are sensitive to individual needs and interpersonal styles. Teaching interpersonal styles that are radically different to the individual’s own interpersonal style is not as likely to be as effective as working on the person’s own interpersonal style in order to enhance their assertion skills.

4. This is a practical skill that needs to be demonstrated and practised through the use of non drug and alcohol related examples and through the use of role plays.

Review Homework

This reviews the diaries of angry situations. This includes situations that caused annoyance and irritability and should not be limited to angry or aggressive situations. If the assignment has not been completed, think about one recent situation during the session.

Have there been any situations that have made us angry or irritated since the last session?

How did the person cope in each of the situations and was there anything that they could have done differently to improve the outcome.

What were the automatic thoughts in this situation and how did the alternative thoughts change the feelings of anger? Did they/could they use the assertion skills developed in the last session? What was the outcome of this?

Exercise 1: How do other people influence us?

This exercise looks at how and why other people want to influence us even though it may not be in our best interests. It explores the types of situations in which our decisions are being influenced and to what ends. This aims to normalise the experience of being influenced and to introduce the concept of ‘double think’ understanding situations from our own and other people’s situations.

Session Objectives 1. Look at how other people can influence our use of drugs and alcohol.

2. Look at our beliefs about what other people think when we say “no”.

3. Explore how these contribute to high risk of relapse situations

4. Learn assertion techniques through demonstrations

5. Practice these techniques using role plays

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In what situations do other people influence us generally?

Elicit all the types of influence that can be exerted over people. Place these types of influence across a spectrum of either conscious (explicit) or unconscious (implicit) influence. Conscious (explicit) ------------------------------------------- Unconscious (implicit)

E.g. Direct orders Advertising Persuasion Peer pressure

Rules Propaganda

What are all the techniques people use to persuade us to do something? (also in handbook) Elicit different types of persuasion that can be used socially?

Write the four types of persuasion on the flipchart and give the definition of each. Try and get as many examples of each from contemporary advertising, expression or social situations:

1. Bandwagon “This is when people make you feel that you will be part of a desirable group of people. This technique also makes you feel that if you do not go along with the idea then you are somehow less desirable: unfashionable, isolated or un-cool.”

a. Peer pressure E.g. “People who know music, know the Underground Club” b. Testimonials “I did it and it was great” e.g. Using famous people to advertise or endorse products e.g. “I was so happy, I bought the company” c. Group psychology: “If you buy this or do this, you can join our group” e.g. “Everybody is using the internet these days”

2. Repetition “This is when a sentence, phrase, song or jingle is repeated frequently to get you to remember it or even believe it”

a. Frequently seeing images or hearing messages can influence what we think or spend. e.g. “You’re lovin’ it …McDonalds”; “Coke is it..” b. We are more drawn to familiar objects, people, tunes, tastes and foods. e.g. Nokia mobile ring-tone c. We are more persuaded by repetition e.g. “Guaranteed to make you feel better. Guaranteed to make you look better. Guaranteed that you are better”

3. Association

a. Positive association with beautiful people or ideal situations e.g. Seeing beautiful women on around a car b. Negative association with undesirable people or situations. e.g. “Only a fool would go on holiday to Iraq” c. Implicitly associates positive images with products e.g. washing powder and blue sky –> your clothes will smell this fresh and clean.

4. Guilt and anxiety

a. Making the person feel guilty for not doing something e.g. “What sort of person would you be if you couldn’t help a friend out b. Making someone feel anxious about something. e.g. “Just imagine the germs in your bathroom”

5. Free offers and bargains

e.g. “It’s free - too good to be true”

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How are advertisers attempting to influence us in these adverts

Bandwagon: Advertisers are attempting to identify smoking Chesterfield with working class.

Association: Association with happiness

Association: Alcohol with beautiful women and happiness

Association: Alternative thinking and image. Artistic association. Cool language Exercise 2: What are the ways people influence our use of drugs or alcohol?

This exercise attempts to expel the myth that people influence us only by offering us drugs and alcohol. We can be influenced by the sense of belonging that using drugs and alcohol gives us and simply by seeing other people using. Seeing other people use can normalise the use of drugs and alcohol, making us feel that it is normal and acceptable.

How do other people influence our use of drugs and alcohol? What is the difference between spoken (explicit) vs. unspoken (implicit) influences? Is it just through offering substances? Is it sometimes free the first time?

How can you influence another person’s decision to use drink or drugs?

Invite participants to take turns in influencing the rest of the group to use alcohol or drugs. Encourage them to be as creative as possible in doing this Do not give instructions as to how they can do this, but leave it up to them to decide how. Individual can invite other participants to help them with their role-play if that would help them persuade the rest of the group.

BREAK Exercise 3: How do we cope with social situations?

This exercise aims to explore participants ways of dealing with social influence. The emphasis is on planning around situations so that people are not drawn into high-risk situations by other people. Planning includes avoiding situations, warning other people that they are not using and thinking about stated limits (the bottom line). What are all the ways of coping with social influence? E.g. Saying no to people Ignoring people Staying away from people that are going to influence Knowing where to draw the line.

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Anticipating the situation and pre-empting it. I.e. saying that you have stopped drinking or using drugs before someone offers

There are a number of techniques that help in dealing with social situations.

1. Plan for the situation in advance

a. Think what are the temptations going to be b. Think what is the line that you do not want to cross c. Think about how you are going to deal with temptation

2. Avoid a difficult situation a. If you think that a situation is going to be too tempting or too difficult in other ways avoid the

situation. b. Think of something else to do instead so that you do not feel deprived c. Tell people in advance so that there is not an expectation that you will be using substances.

(E.g. I’ll meet you in the pub, but I’m not drinking.) 3. Plan your coping strategies

a. Think about the consequences of using substances to excess b. Think about the length of time that you have not used to excess and how well you have done

so far. c. If you feel yourself giving in to temptation, leave the situation.

4. Feel good about coping with temptation Exercise 4: Broken Record Skill

The broken record skill is a way of saying no to other people who are trying to persuade us to do something that we really don’t want to do. It can also help us say no to ourselves.

Rules for the Broken Record Technique 1. State your position. 2. Do not feel that you have to explain your position. 3. Do not become emotional in your responses. 4. Repeat your position every time that you are questioned. 5. Keep repeating it until the person eventually gives up.

Example of Broken Record

Facilitators should first demonstrate the broken record technique. A: ”Go on, let’s have a drink” (Bandwagon) B: “No thanks, I’ve stopped drinking” A: “Go on, I haven’t seen you for ages” B: “No thanks, I’ve stopped drinking” A: “Don’t worry, I’ll get you one if you’re skint” (Free / Bargain) B: “No thanks, I’ve stopped drinking” A: “Have a drink with your old friend. You can’t leave me to drink on my own” (Guilt) B: “No thanks, I’ve stopped drinking” A: “What sort of person wouldn’t even have a drink with their mate” (anxiety) B: “No thanks, I’ve stopped drinking” A: ”Only losers wouldn’t stop to have a drink with a friend” (association/guilt) B: “No thanks, I’ve stopped drinking” A: “Well, don’t worry, maybe we can have a drink next time”

What were all the persuasion techniques in this role-play?

Try and persuade someone to do something In pairs, invite participants to try and persuade the other person to do something that they do not want to do. The other person should use the Broken Record Technique to say no to the other person.

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Assignment: Diary of Coping with Persuasion This exercise records the individual’s ability to cope with persuasion. It not only records their ability to resist the use of drugs, but doing anything that they don’t want to do. It would not be helpful to resist doing things that they are obliged to do as part of their care or treatment such as taking medication or working with their care team.

Identify any situations in which people have tried to persuade them to do something. Write down How Risky that situation was, and how much it would be likely to put them at risk of

using drugs or alcohol if they were in the community. Write down what they did in response to persuasion.

Write down the outcome of the situation and how well they felt that it turned out 10 = Very Good E.g. Resolved problems without walking away or getting angry 0 = Very Bad E.g. became angry and hit the man

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SESSION 20: Getting Support INTRODUCTION

This session looks at how friends, family, acquaintances or professionals can either help support people in staying off drugs or alcohol, or how they can increase the risks of using drugs or alcohol. It looks at the type of risks with each person and in each social circle. It looks at how you can get people to help you manage high-risk situations, thoughts and feelings about using drugs or alcohol. Key Issues: 1. Different people or groups of people can provoke high-risk situations through different means as well

as creating opportunities for using drugs and alcohol. 2. Understanding how different people place us at high risk of using drugs and alcohol can help us

manage these situations better. 3. Social support can be developed though active recruitment as well as through existing family friends. Review Assignment

This reviews the diaries of coping with persuasion. This includes situations that caused annoyance and irritability and should not be limited to angry or aggressive situations. If the assignment has not been completed, think about one recent situation during the session.

Has anyone noticed any situations in which we have been persuaded of something? Think about the types of media that they have been exposed to or the types of social interaction

and how persuasion was used in these situations. Elicit ideas from participants and think about what type of persuasion this could have been: I.e. Bandwagoning, Repetition, Association, Guilt or Anxiety, Offering bargains.

How did participants cope with this persuasion?

Before reviewing the written assignments, review each of the types of persuasion discussed and ask other people to comment on how best they could have coped with that persuasion. E.g. Assertion skills, Ignoring, Broken Record, etc

Review the written exercises of the week’s dairies. Exercise 1: How are some people or social situations not helpful?

This exercise aims to draw out how (not who) social situations can contribute to high-risk situations. This can be through providing situations of temptation but also by other means including provoking arguments that can lead to moods and thoughts that are high-risk, people who make you feel bad about yourself. This can be through thinking about positive role models that use drugs or alcohol, it can be through being with groups who make using drugs or alcohol to excess seem normal.

Session Objectives 1. To look at the risk and help with each person and social group that we know.

2. To look at how we can manage the risks without losing friends.

3. To look at how we can access help from people without feeling embarrassed.

4. To look at how to get your care team to support you in staying free from drugs or alcohol.

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OHP Relapse Prevention (session 10) When we are climbing the mountain, some people can help us get to the top and some people can drag us down and knock us off the mountain. In this session we are going to be looking at which people can help us and which people can harm us.

How can someone else place us at high-risk of using drugs or alcohol? 1. What? What substances would people be worried about using to excess in the future? E.g. I don’t want to go back to taking cannabis all day. 2. When? Invite participants to think of all the times that they have such drugs or alcohol when

they have been with other people, or after seeing other people. E.g. Usually when in a crowd that’s having a good time. Talking to someone one-to-one, 3. How? Identify what were the sort of things that these people would say or do that led to using

drugs. E.g. People telling me what to do. Being offered a drink. 4. Why? What is it about what they do or say that changes something in us that places us at

high risk of using drugs or alcohol? E.g. Offering drugs. Inviting us for drinks. Using alcohol themselves. Knowing that they have cannabis. Listening them talk about how cannabis inspires them. When I get really angry, only cannabis can calm me down.

Let’s think about how these social situations can put us at risk of using drugs or alcohol?

Revisit all of the high-risk social situations discussed and discuss which of the three categories on the flipchart they come under: 1. Creating high-risk situations E,g, People who put temptation in my way. 2. Creating high-risk moods E.g. People who make me nervous and want to drink 3. Creating high risk thoughts E.g. People who make me think that using cannabis is normal.

Place the flipchart paper on the wall to one side ready for the next exercise.

Exercise 2: How can some people or social situations be helpful?

This exercise looks at the converse situation and thinks about people can be supportive and make it feel OK not to use drugs or alcohol. This can either be through not creating high-risk situations, helping us deal with other people better, helping us cope with emotions, helping us change our thinking about using drugs or alcohol. Some people can also provide good role-models who we respect or admire who do not use drugs or alcohol to excess.

How can other people help us cope with drugs or alcohol? Think about how different people can help us in different ways. Think about all the positive role models, emotional supporters, active supporters: 1. Helping us cope with situations that put us at risk of using drugs or alcohol E.g. Knowing that I find situations tempting and helping me deal with them.

Inviting me to situations that do not put me at risk. 2. Helping us cope with feelings and moods that lead to drugs or alcohol E.g. She’s good at listening when I’m down and feel like having a drink 3. Helping us challenge our thoughts about drugs or alcohol E.g. Showing me that it’s OK not to use drugs or alcohol

Place the flipchart paper on the wall to one side ready for the next exercise.

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Exercise 3: Drawing a Social Network Map

This exercise looks at “Who?”. It aims to identify the people in the network that can be useful and risky. If participants are reluctant to write down the actual person’s name they can use some other form to identify them, also using symbols to indicate who they mean.

Make different coloured paper available to indicate risk in the social network

Which of the people around us are supportive or risky? 1. Draw an example of a social network with the fictitious names of people. 2. Describe the links between people and how often you see them and where. Which other people

are in this situation and how do they affect the situation? 3. Write down some of the risks and supports for each person. Some people may be risky and

supportive in different situations and for different reasons.

BREAK Exercise 4: How to recruit social support?

This exercise looks at how to tell people that they plan not to use drugs or alcohol and in some circumstances the reasons why? Participants may find it difficult to think about telling other people about their own personal problems and so this exercise may seem somewhat unnatural to them. It is normal that participants would be uncertain about other people’s reactions (disappointment, fear, etc), but this uncertainty depends on

How can we get others involved in supporting us? Go through each of the points (1-5) getting examples of the sort of statements participants can make so that they do not feel over-exposed or embarrassed, but also so that they can get their point across.

1. Chose the right person to share personal information:

Choosing the right person is extremely important, as we do not want to share personal information with all people. It is important that the people that we rely on will not let us down and will keep our best interests at heart. E.g. Close family member or brother or sister. Someone who does not use drugs or alcohol to excess themselves.

Me Michael Cannabis user

John Heavy Drinker

Parents Non-users

Girlfriend Non-user

Michael’s friend Dealer

Michael’s girlfriend Non-user

Brother Cannabis User

Sister Non-user

Supportive

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2. Describe the problem but also our goals:

In order get people to support us we need to give them some information about ourselves and how drugs and alcohol have been a problem for us in the past. In this we need to understand the problems associated with drug and alcohol use and how these have effected us in the past. E.g. “In the past I have found myself smoking all day and this effected my mental health. I am hoping to stop using cannabis altogether and only drink on social occasions”

3. Share information about how drugs can effect a mental illness.

So that people can understand why this is a particular problem for you, it is important that they understand something about how drugs and alcohol can affect people with a history of mental health problems. Your care team will be able to provide you with some information about mental health problems, or your supporter may want to look these up on the internet. E.g. “Smoking cannabis can be OK for many people, but because I have had mental health problems, it can cause me more problems than others.”

4. Describe high-risk situations

If people are going to help you stay off drugs and alcohol, it is important for them to understand what situations that you may find difficult. You may want to give them general information about your high-risk situations (e.g. being offered a drink), or get them to help you with specific difficulties. E.g. I find it particularly difficult when I get bored and feel down about things. It’s really important to me that I keep myself busy so that I don’t think about using cannabis”

5. Sharing the plan to manage drug or alcohol problems. It is important that people who are supporting you know where you want to be with your drug and alcohol use and how they can help if you are not keeping to your goals. E.g. “It’s really important that I don’t just start to smoke cannabis every day. If I do have a joint it’s really important that I don’t let a slip become a full relapse and that I don’t smoke after that. If It’d be really helpful if you could remind me to stay on track if I start smoking again. My community supervisor also said that it’d be OK if I told them when things were getting difficult”

Getting someone to support

1. Ask each participant to identify one person from their social network to help them manage their use of drugs and alcohol.

2. Invite another participant to role play the person identified to help support 3. Ask each participant (one-by-one) to go through the steps for recruiting social support. 4. At the end of the role-play, ask the participant and co-actor to comment on how it felt. 5. Ask the rest of the group to comment on whether they think that it would be effective

What can be some of the difficulties in getting this type of support?

Elicit some of the problems that participants think they would have in getting some support. Were there any issues from the role-play that could prevent others from helping? E.g. “Asking someone for help makes me feel that I’m going to let them down” “Asking for help feels like I can’t manage on my own” “I don’t want to tell other people about my personal problems” “People will think that I’m mad” “It’s embarrassing”

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Exercise 5: How to recruit professional support? This exercise looks at how individuals can use their care team to help them remain abstinent from drugs or alcohol. There are no recommended strategies as the service and policy will vary from area to area.

How can your care team help you stay off using drugs or alcohol? Discuss some of the following points: 1. What resources are available to you? 2. Will you have a community supervisor? 3. How can the group help each other? 4. How can professionals help you to manage your substance use? 5. What would happen if you reported a slip? Would this effect your leave/discharge? 6. Could you start a voluntary self-monitoring scheme where any test positive would lead to increased

help with your relapse prevention plan rather than punishment. 7. Are there any medications to help stop me from relapsing if I’ve had a slip (e.g. antabuse)? 8. How can the team help with decisions on housing or hostels that will minimise the risk of relapse? 9. Could the team help me talk to my family to get them to help me?

How would you like your team to help you remain abstinent in the community? We will be reviewing some of the community resources in session 24 Assignment: Getting Professional Support

This assignment invites participants to meet with their care co-ordinator or Responsible Medical Officer to discuss the ideas that have been developed that would help them remain abstinent in the community.

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SESSION 21: Quitting after a slip INTRODUCTION

This session looks at how to keep on giving up after a slip. It looks at the type of thoughts that can make you want to give up giving up and the type of thoughts that make you want to get back on track. It also looks at what you can do after you’ve had a slip to stop it from becoming a full relapse. These ideas can also be useful when trying to limit your use: not letting one beer become five. This can be the difference between having a bad day the next day and feeling that you don’t need to stop giving up. Remember, the sooner you get back on track, the easier it is going to be to remain abstinent. Key Issues: 1. The difference between a slip and a relapse depends on the decisions and the actions that are taken

after the slip. 2. There are a number of thoughts, decisions and actions that can prevent a slip from becoming a

relapse. 3. Relapse prevention is possible at any stage of relapse, whether thinking about using, after using

once, or after a binge. Review Homework: Review the plans for professional help.

This review assesses what arrangements people thought up to get their care team to help them remain abstinent from using drugs or alcohol. How are they going to take those forward? This information is going to be used as part of the final relapse prevention plan and so should be kept for later. Exercise 1: Introduction to relapse prevention?

OHP Relapse Prevention (session 10)

Use the analogy of climbing the mountain to describe that the sooner people start climbing again the less damage that is done and the closer it is to the top.

Exercise 2: What happens after a slip? This exercise explores the type of feelings you can have after doing something that you had decided to stop. This exercise focuses on the use of drugs, but it can also focus on any activity that people decide not to do (e.g. eating take aways, watching late night television, smoking cigarettes etc). Cut out (A4 size) thought bubbles and give marker pens to write thoughts on them.

Has anyone ever done anything that they said they weren’t going to do? Ask participants: 1. What were the kind of thoughts they had afterwards? E.g. “I don’t care anymore”; “That was a mistake, I’ll stop again in the morning” 2. How did they feel about themselves? E.g. “I’m useless, I may as well not try to give up”; “I always mess up, I can do better than that” 3. Did they carry on, or did they stop afterwards. 4. Ask participants to divide statements into statements that will held and those that won’t

Session Objectives 1. For participants review the difference between a slip and a full-blown relapse.

2. For the group to examine the type of thoughts and feelings following a lapse.

3. To identify which of these thoughts and feelings make relapse more likely.

4. To look for alternative thoughts and feelings that reduce the likelihood of relapse.

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Ask participants to write on of each type of relapse of coping thought from the flip chart onto two

thought bubbles. Exercise 3: Thoughts and decisions

This exercise develops the concept that thoughts can affect actions at different stages of the relapse process. It looks at the different types of outcomes depending on the different types of thoughts. The group should be involved in developing the story and then role playing the different outcomes as a result of these thoughts. This exercise also uses the Relapse Prevention Plans developed in session

John’s Story Put John’s picture on the flipchart and Introduce John and develop the scenario with the group: John has been abstinent from [e.g. cannabis] for 3½ months and he goes to a [e.g. party] where he meets some old friends who are drinking and using [e.g cannabis]. Originally, he had intended to have a few drinks and go home early as he has to [e.g. work] in the morning. His girlfriend decides to go home early and his friends start to smoke [substance]. John smokes a joint and starts to feel high. Then he thinks…

Role-play the relapse scenario All participants should be part of this role-play. Each participant takes turns in developing the scenario depending on the types of relapse thoughts that John is having

1. Each participant should have a thought bubble from the last exercise. 2. Place the thought bubble on the flipchart next to John and role-play what John would do as a

result. 3. The reset of the group act as John’s friends in the situation.

How did the different thoughts change the outcomes from each scenario?

Explore which thoughts were more helpful in getting back on track Have we got any choice over the type of thoughts that we have in such situation? BREAK

I’ll feel better in the morning if I stop right now.

I’ve blown it now. I may as well just give up giving up

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Exercise 4: When is a good time to stop?

This exercise describes the vicious cycle of relapse from temptation to slip to relapse. It also describes the typical thoughts that go with that process and how different kinds of thoughts and actions can prevent a slip becoming a relapse.

What are all the stages of relapse in which we can stop again? Ask the group to think about a situation in which they had a slip and started to use drugs or alcohol although they had wanted to give up. Ask when they think they would stop again. i.e. After single use. The next day. After the weekend

Draw the relapse cycle on the flip-chart.

1. Describe the different stages of the relapse. 2. Ask when would be the best time to stop again? 3. Write down the different thoughts that people can have at different stages. E.g. “There’s no point in giving up now”

“If I stop now, I can still get myself back on track” “I’ll stop again tomorrow / after the weekend / next week / after my birthday…”

4. Which of these thoughts could help to stop a slip becoming a relapse? 5. Think about whether these thoughts would make them continue on the relapse circle or return to

stopping. 6. Write the helpful thoughts on the flipchart in thought bubbles.

Write in handbooks positive statements that can help get a person back on track after they have

had a slip.

What can you do to get yourself back on track again? Elicit ideas for the type of actions that can be taken when stopping after a slip. Discuss how effective these could be. E,g, Leave the high risk situation and feel good about having managed this situation. Think about the consequences of using more.

Do something nice instead Use thought distraction, mindfulness

Remember, the sooner you stop again, the easier it is. It is never too late. Making positive statements to yourself can help get you get back on track.

Feel like using Drugs or Alcohol?

Next Day

Relapse Had a Slip

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Exercise 5: Fixing Limits This exercise looks at how relapse prevention skills can help prevent low levels of substance use escalating into problematic use. It is necessary to be clear that the easiest way to stop the damaging effects of substances is to stop using altogether. However, some people do not want to stop all substances altogether and it is important to help limit their use. Most people will recognise that there is always a limit when drugs or alcohol become unpleasant. Most people do not stop at this point because they do not recognise their limit, or because they are not thinking about the consequences. This is a harm reduction exercise in damage limitation.

If you are going to use drugs or alcohol, how do you set your limits? Is it necessary to set limits? How do you decide what is the right amount?

What could be the consequences of using to excess? [Reflect on session 6 when the group thought about how different levels of use affected their behaviour] When does use become abuse?

How can your stop at your limit?

1. Plan your use before you start. Once started it is harder to fix limits. 2. Recognise when you have reached your limit. E.g. Starting to become over-familiar with people, thinking paranoid thoughts, losing control over social situations 3. Think thoughts that will help you stop at your limit. E.g. “If I stop now, I’ll feel better in the morning”; “if I stop now I’ll have a better night” 4. Do something that will help you stop at your limit. E.g. Plan to leave at a certain time; Pace yourself so that a drink can last longer

What are the dangers to look out for?

Discuss the type of difficulties in sticking to self-limits. Think about the particular difficulties when using drugs or alcohol. E.g. Getting a taste for it. Becoming less strict with yourself after one [drink / joint] Letting yourself give in. What are the risky type of thoughts when trying to stop at a limit.

1. Ask each participant to describe on situation when they have planned to use less drugs or alcohol than they have actually used.

2. Ask them to describe the situation and find out what was the turning point when they gave up sticking to a limit.

3. What were the thoughts at this time and what did they do as a result. 4. Ask each person what they could have done differently.

Assignment: Fixing Limits Practice This exercise uses currently used drugs or alcohol or practice damage limitation. In some circumstances, the drugs and alcohol are not available and so other substances can be used in order to practice damage limitation.

Think of something that you would like to limit or cut down? Elicit some of the habits or behaviours that people would like to practice changing for one week. E.g. Smoking cigarettes, going to bed late, playing on the Play Station Invite participants to fix a limit in writing on that activity until the next session. Have a discussion with each participant about how they are going to keep to that limit. Think about the dangers / risks in each situation

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What the hell. I’ve started now. I may as well just carry on.

OK, I’ve just had a slip. I can stop here and I’ll feel so much better.

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I’ll feel better in the morning if I stop right now.

I’ve blown it now, I may as well just keep on going…

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SESSION 22: Skills Practice INTRODUCTION

This session aims to review the skills that we have developed in the relapse prevention and skills development modules. It looks at what we have learned and asks you to get involved in reviewing and practising these skills. Key Issues: 1. It is important to remember that although determination is essential to stay free from using drugs or

alcohol, will power is not enough on its own. 2. It is important to develop a range of skills that can be used in different situations. 3. Different skills will suit different people depending on their typical high-risk situations and on the

individual. 4. Different skills can be used in different situations. It is important to differentiate these depending on

whether people are at home, outside, alone or in company etc. 5. There are common features to different skills that make them similar although some people will

prefer some skills over others (e.g. mindfulness or relaxation). Review Assignment: Fixing Limits

This section reviews how participants were able to fix limits on behaviours. It is important to emphasise that this is a practise exercise to see what challenges there may have been in fixing limits.

What behaviours, habits or activities did you decide to fix a limit on from last session? 1. What were the limits you fixed? 2. Were there any difficulties in sticking to these limits? 3. Did you worry about breaking these limits? How did you feel? 4. What were the types of things that you said to yourself if you broke these limits? 5. What could have helped you stick to your limit?

E.g. Social support, getting encouragement, not making excuses to myself 6. Would any of these problems be similar if you limited your drug or alcohol use?

Exercise 1: Skills Presentation

This exercise invites participants to introduce and practice one or two of the skill steps each. It should be remembered that participants may find it challenging to present a skill to the rest of the group, so they should be given the choice about whether to do this from the front of the group or in their place. Assistance may also need to be provided in describing each of the skills. The following materials will be necessary: Cut out skills cards

Tape recorder/CD for relaxation exercise Packet of sultanas for the mindfulness exercise Red Flag Cards

Session Objectives 1. To revise the skills that have been developed in the relapse prevention and skills

development modules.

2. Think about how each skill can be used different situations.

3. To practice these skills using scenarios or role-plays.

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This is your opportunity to describe the skills that we have learnt to the group

Hand out one or more of the skills cards to each member of the group. Give them several minutes to think about the skill and prepare what they are going to say. Ask each participant to describe:

1. When that skill would be useful 2. How to use that skill 3. Give a demonstration of that skill either through role play or through talking through the skill. 4. Ask the group to give each person feedback about their presentation

BREAK Exercise 2: Practising Skills

This exercise uses short scenarios to practice some of the skills that have been presented in the exercise one. Participants are given one scenario each and invited to use one of the skills to manage this situation. It is important that these scenarios are made to be as realistic as possible within the limitations of the group. These scenarios can be fun and people should be congratulated on their acting skills.

We are going to practice some of these skills. 1. Organise the group into pairs to role-play against each other. 2. Give each couple a scenario from the role-play cards. 3. One person is give the first part of the role play and the other person is given the second part

of the role play 4. Describe the situation to the group and ask each pair up to the front of the group to practice the

skill given on the role-play card. 5. At the end of each role-play, get feedback from the group. Was this realistic? How effective do

they think that skill would be for them? Would they use that skill in that situation, or another skill? Assignment: Which Skill?

This assignment aims to get people to think about how they can use the skills in different situations. Whilst there is no single skill that can be used to manage any single problem, this aims to get people to think about how to manage a high-risk situation.

In the handbooks, write down the skill that you would use to manage each of the situations described (1-10). There is no single answer but think about why you decided to use that skill rather than another skill.

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Red Flag Use the red flag in emergency situations when you think that you are likely to use drugs or alcohol and other relapse prevention skills are not helping. Use this when you feel that you are about to have a slip or relapse:

1. Stop thinking about drugs or alcohol and think about something nice E.g. Going on a nice holiday or seeing a friend or relative 2. Think about your positive goals in life and where you want to go E.g. Think about ambitions and favourite thoughts about the future 3. Think about the negative consequences E.g. Think about going back to hospital or prison due to mental health problems 4. Leave the situation that would put you at high-risk of using drugs or alcohol E.g. Walk out of the house and go somewhere that you like going 5. Do something nice with the money instead E.g. Go out and buy your favourite food or treat yourself instead

Keep your red flag card on you and write your reminders on the back

Changing our Thoughts Changing thoughts is particularly helpful when we are being tempted by our thoughts and we find ourselves justifying our use of drugs or minimising the problems with alcohol, normalising our use or denying the amount we are using. Check your automatic thoughts by asking the following questions:

1. What is the evidence that the automatic thought is true? E.g. “If I didn’t get a drink, then I would still be OK”

2. Is there an alternative explanation? E.g. “Maybe I just want a drink because I’m feeling down”

3. What’s the worst that could happen? Could I live through it? E.g. “If I don’t get a drink, I’m not going to die”

4. What should I do about it? E.g. “I’ll can just have a drink of soda and lime to refresh me and then I’ll feel better”

5. What’s the effect of believing my automatic thought E.g. “If I believed my automatic thought, I would just go and have a drink”

6. If a friend of mine / family member was in this situation and had this thought, what would I tell him/her? E.g. “I would tell them that they don’t really need a drink, they just think that they need a drink because they are craving”

7. Make a more helpful thought that will not make you feel like using drugs or alcohol E.g. “If I have a drink, I’ll only want to drink more then I’m back where I started”

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Changing our Moods

We can change our moods when our feelings or moods are putting us at risk of using drugs or alcohol. This might be when we feel particularly happy, or particularly sad or anxious. We can change our moods by trying a number of different ways:

1. Letting go of our emotions a. Observe your emotions b. Experience your emotions c. Separate yourself from your emotions d. Accept your emotions

2. Changing our emotions by acting in the opposite way a. Change your high-risk emotion by acting, thinking or feeling in an opposite way

3. Using distraction to manage our emotions a. Use activities to distract yourself b. Get involved with something c. Use thoughts to distract yourself d. Use sensations to distract yourself

4. Using self-comfort to manage out emotions a. Vision – look at something beautiful b. Hearing – listen to or play something beautiful c. Smell – use aromas to create a new or beautiful atmosphere d. Taste – eat or taste something new or beautiful e. Touch – use sensations to feel good or experience something new

Urge Surfing We can use urge surfing when we feel cravings that are placing us at high-risk of using drugs or alcohol. This is when we let go of these cravings and temptation. You can do this by thinking the following or making your own version: • The feelings of temptation and craving that you are experiencing are only in your mind. Let

these feelings wash under you. You are floating above these feelings of temptation and craving.

• These feelings are no longer inside you, but below you like a wave. • These feelings will not drown you, they will make you stronger. They are carrying you to an

island where drugs and alcohol do not exist. • Let these feelings of temptation and craving roll beneath you, like a wave. • You have arrived in a world with no drugs or alcohol. There are no drugs and there is no

alcohol here. • You are on dry land now. You can feel the warm sand on your back. The feelings of

temptation and craving have washed away. • You do not want to drugs or alcohol. They do not exist. • You feel warm and happy here. There is no more temptation or craving. • You feel good about yourself. You have arrived where you want to be… • Slowly open your eyes.

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Relaxation

We can use relaxation to either cope with cravings to use drugs or alcohol or with stressful situations or moods that might make you feel like using drugs or alcohol. You can use the progressive muscle relaxation tape/CD or do these exercises without playing the tape/CD. You need to:

1. Find a quiet place 2. Sit or lie comfortably without crossing your arms or legs 3. Let your mind still without forcing yourself to stop thinking 4. Play the progressive muscle relaxation CD 5. Use your breath to relax each of the muscle groups in turn 6. Spend some time enjoying the moment 7. Let go of all your worries and stresses

Self Statements

Self Statements are statements you make to yourself to remind yourself of some of the reasons for not using drugs or alcohol. These should be used to encourage yourself when people, situations or thoughts are tempting you to use drugs or alcohol. Rules for Self statements

1. Self statements should help you think about your goals and ambitions E.g. “Drugs or alcohol won’t help me get that job” 2. Self statements should reflect a positive outcome from not using drugs or

alcohol E.g. “Think about the family” 3. Self statements should help to think about the negative consequences of

using drugs or alcohol. E.g. “I don’t want to go back to hospital or prison again”

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Mindfulness Skill

Use the mindfulness skill to focus your thoughts away from drugs and alcohol and onto a pleasurable activity. • Hold a sultana between your fingers. • Try to focus your attention on the sultana without holding on to any particular thoughts, but

without pushing thoughts away. • Let the experiences of the sultana go through you mind and slip right out. • Become alert to every thought and sensation about the sultana that comes into your mind. • Look at the surface of the sultana, its colour and how the light reflects from it. • Feel the texture of the surface of the sultana. • How does it feel when you turn it between your fingers? • Think about how soft or hard the sultana is. • Place the sultana in your mouth and before chewing, experience the texture and feeling in

your mouth. • Feel how your mouth reacts and starts to produce saliva. • Start to slowly chew the sultana and as it breaks, how the texture feels between your teeth. • Taste the sultana as you chew. • Feel the sultana as it falls to the back of your throat, being swallowed and going down • Do not hold on to any of these experiences but let them flow right through your mind. • Do not separate yourself from the experience, but let yourself become one with it, like

dancing to music.

Assertion Skills

Use assertion skills to deal with angry situations with other people. These skills can help you feel in control and successful in coping with difficult situations.

1. Prepare yourself to deal with a difficult situation but remind yourself that you can do this without becoming angry or aggressive.

2. Think about why you are annoyed and what needs to change. State what the problem is in your opinion. E.g. “I think that you are being rude when you talk to me like that…”

3. State how you feel about the problem and how this effects you (people cannot disagree with your feelings). E.g. “I feel really annoyed when you talk to me like that…”

4. State what, in your opinion, you think is the solution. E.g. “We would get on better if you could talk to me without being rude..”

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Saying “No”

Saying “no” to drugs and alcohol can be used when people are offering you drugs or alcohol. This can help let people know where you stand without offending them or giving in to persuasion.

Rules for the Broken Record Technique: 1. State your position. 2. Do not feel that you have to explain your position. 3. Do not become emotional in your responses. 4. Repeat your position every time that you are questioned.

Coping with Symptoms

There are a number of ways of coping with some of the symptoms associated with mental health problems.

1. Distraction “Distraction can be used with a number of symptoms of mental illness. It works by taking your attention away from the symptom that my be causing distress or uncertainty, and focusing the mind on something else”

2. Grounding / Normalising “Grounding or normalising describes the process of making your experience real. It works by focusing on the things that you are certain about, rather than the things that you are not sure about. You can do this in a number of different ways, but we are going to practice by describing the immediate environment”

3. Focussing/Concentration “This exercise is designed to take the focus away from some thoughts and place them onto others. It works a little like distraction, but rather than taking the mind away onto many other things, it narrows your thoughts onto one thing. This can be focusing the mind onto something nice such as an image or person, or something positive, like a self-statement”

4. Reality Testing “Reality testing is helpful to get a shared understanding of what is going on. This can be done in asking other people what they think is happening. It does not have to be a direct disclosure of what you are thinking but some question that will help you to test your reality”

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Recruiting Support

Recruiting support is important when looking for people to help you to stay free from drugs or alcohol. It doesn’t matter whether you are living with them or not, other people can help support, encourage and watch out for you. 1. Chose the right person to share personal information

Choosing the right person is extremely important, as we do not want to share personal information with all people. It is important that the people that we rely on will not let us down and will keep our best interests at heart.

2. Describe the problem but also our goals In order get people to support us we need to give them some information about ourselves and how drugs and alcohol have been a problem for us in the past. In this we need to understand the problems associated with drug and alcohol use and how these have effected us in the past.

3. Share information about how drugs can affect a mental illness So that people can understand why this is a particular problem for you, it is important that they understand something about how drugs and alcohol can affect people with a history of mental health problems. Your care team will be able to provide you with some information about mental health problems, or your supporter may want to look these up on the internet.

4. Describe high-risk situations If people are going to help you stay off drugs and alcohol, it is important for them to understand what situations that you may find difficult. You may want to give them general information about your high-risk situations (e.g. being offered a drink), or get them to help you with specific difficulties.

5. Sharing the plan to manage drug or alcohol problems

It is important that people who are supporting you know where you want to be with your drug and alcohol use and how they can help if you are not keeping to your goals.

Fixing a Limit

Fixing a limit can be used when you have decided to use moderate amounts and feel that you can stick to your limit without being tempted to go over this limit.

How can your stop at your limit?

1. Plan your use before you start. Once started it is harder to fix limits. 2. Recognise when you have reached your limit. E.g. Starting to become over-familiar with people, thinking paranoid thoughts, losing control over social situations 3. Think thoughts that will help you stop at your limit. E.g. “If I stop now, I’ll feel better in the morning”; “if I stop now I’ll have a better night” 4. Do something that will help you stop at your limit.

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Scenario 1: Assertion Skills

Situation: You have been abstinent from using cannabis for 18 months now. Since returning into the community you have been keeping yourself busy and not thinking about smoking cannabis. Whilst working as a painter and decorator, another worker offers you a puff of his joint. You decline his offer, but you are worried that he might smoke in front of you or offer you a smoke. You don’t want to offend him or fall out with him as you usually get on well, but it is important that he doesn’t smoke in front of you.

Role Play Use your Assertion Skills to ask your colleague not to smoke in front of you at work or offer you drugs.

2Scenario 1: Assertion Skills Role Play: You’ve been working in this job as a painter and decorator for several years. You have always smoked cannabis in the afternoon. You usually smoke outside but on one occasion you are in a hurry and smoke whilst working. Just to be polite you offer a colleague your joint but you get the impression that he is not happy. You don’t mind smoking outside but you aren’t going to stop smoking altogether just because someone else does not like it.

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Scenario 2: Broken Record

Situation: Since leaving hospital, you have been determined not to drink as much as you have in the past as this caused problems leading to your last admission. However, you still want to drink as it is a sociable thing to do but you have decided to fix your limit at one pint. You regularly meet with a friend of yours and he usually drinks more than one pint. You are determined not to drink more than one pint on any day and want to stick to this.

Role Play Practice saying “no” to another drink and sticking to your limit of one pint. Use the Broken Record Skill if necessary.

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Scenario 2: Broken Record Role Play: You have been going to the pub for several months to have a drink with your friend. Each time you meet he buys you the first pint, but then refuses when you offer him a drink in return. You haven’t minded this in the past, but now it is getting embarrassing. You are determined to buy him a pint regardless of what he says.

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1Scenario 3: Getting Support

Situation: When you first left hospital, you were so happy to be out. Since this time, things have been getting harder as you can’t seem to survive on the money you get and it has been really hard getting a job. You were expecting to see your family much more than you do and it seems that they are all too busy to meet up these days. You have found yourself getting more and more down and worried about money. Despite having not used drugs since leaving hospital, you have started to think about them more and more. You are determined not to use drugs again as you know that they aren’t good for your mental health and you don’t want to go back into hospital again. Role Play You ask your brother to come round to ask him for help staying off drugs. Look for any ways that he or the family could support you in remaining free from drugs or alcohol.

2Scenario 3: Getting Support Role Play: Your brother has recently come out of hospital. Before he went in to hospital he used drugs and alcohol all the time but since he has stayed off since he has been out. He seems to be doing so well. You haven’t seen him recently but he is being supported by his care team. He has asked to talk to you about something and you go round to see him.

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1Scenario 4: Challenging Thoughts

Situation: Since being out of hospital, you have started to think more and more about using drugs and alcohol. Life isn’t quite as rosy as you thought it was going to be and much of the time you find yourself alone or having to deal with mental health professionals which you find stressful. However, you are determined not to give in to these thoughts and you want to stay free from drugs and alcohol so that you don’t end up in hospital or prison again. Role Play: The other person in this role play is going to stand behind you and try and give you reasons to use drugs or alcohol. Challenge the reasons that they give you by making your own alternative thoughts or by using self-statements. Each time they give you a reason for using drugs or alcohol, challenge these thoughts.

2Scenario 4: Getting Support This person has just got out of hospital again. Life isn’t great and sometimes it feel that using drugs or alcohol spice things up again. He hasn’t seen his friends since leaving hospital as they use drugs and he doesn’t want to be tempted to use again. He hasn’t even been able to go to the pub as he is worried about starting to drink. He has found himself more and more lonely since leaving hospital. Role Play: You are someone’s tempting thoughts stand behind the person and try and tempt them to use drugs or alcohol by whispering to them as if you were their internal voice. Do this by giving them reasons for using drugs or alcohol. Let them answer each statement before giving them another reason.

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1Scenario 5:

Situation: Role Play:

2Scenario 5: Situation: Role Play:

SESSION 23: Relapse Prevention Planning Revisited INTRODUCTION

This is where we put these skills together to use them to help us stay off in situations that may make us feel tempted to use drugs or alcohol. It does first by reminding ourselves what are the situations that we find it difficult to stay free from drugs or alcohol and trying to find out why these situations are particularly difficult for us. Is it something about the situation or is it our thoughts or moods that are making us feel like using? We are going look at which skills we can use in each of these situations and how we can reduce the risks of using drugs and alcohol. Key Issues: 1. The value of the skills developed relies on them being applied to real and personal situations. 2. For each person’s own high-risk situation, different skills that can be used depending on what is

causing that situation to be high-risk and how the person chooses to approach these situations. 3. Facilitators need to help identify what is making that situation difficult to remain abstinent (situations,

thoughts, moods, symptoms, people etc) and help the person apply a skill that most likely to help them cope with that situation.

4. The skill cards can be used to revise how to cope with each of the different factors that make a situation high-risk.

Review Homework: Which Skill

This reviews participant’s responses to risky situations. Read out the list of situations and ask participants which skill they decided to use in that situation. What other skills could be used in that situation and how would they use that skill. Ask for a few informal demonstrations of how that might work. Exercise 1: Why are our high-risk situations high-risk?

This exercise reviews participant’s high-risk situations (from session 10) and then thinks about what it is about that situation that makes it high-risk. Within each situation it is important to explore what it is about thoughts or emotions that make it high-risk. At this stage, participants should be able to examine these situations in greater depth.

What situation would be the most difficult to cope with? Find out from each person at least one situation that they might be tempted. Work backwards to build up a life snap-shot from this situation to think about:

1. High-risk thoughts in this situation? 2. High risk moods that they might be in generally? 3. What would be their state of mind/mental health that might place them at high risk of relapse?

Session Objectives 1. To review our high-risk situations

2. To understand what it is about these situations that place make us feel tempted to use drugs or alcohol.

3. To revise the skills that have been developed in the relapse prevention and skills development modules.

4. To apply these skills to our own personal high-risk situations in order to improve our ability to cope with these situations.

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4. What would be happening in their life (occupation or housing) that would place them at high-risk? 5. What would be their social situation that would place them at greatest risk?

Write down each person’s number one high-risk situation.

Ask participants to describe the situation that they are in when they feel tempted. Through discussion, find out what are the types of things about that situation that they think would make them more tempted to use 1. Describe the situation. (Top left). E.g. Sitting at home on a Saturday night with a mate who has some cannabis. 2. Analyse the thoughts, expectations and beliefs about that situation that increases the risks

(Top right) E.g. “Saturday night is a time to get high” “I haven’t got any money to go out so I may as well get stoned” “I need to be sociable and smoke with my friends” 3. How is the person feeling? Can this contribute to the risk? (Bottom left) E.g. Feeling quite excited as the week is over Feeling down that I can’t go out and enjoy myself 4. Is there something about the people that you’re with that increases these risks? (Bottom right) E.g. “I don’t always know what to say to people and getting stoned helps” “My friend would feel insulted if I said no” “How could I could I explain to them that I’ve stopped using” “These people are Rasta’s and always smoke”

Place each person’s risk scenario (flip chart page) on the wall for later discussion.

Write these down in the handbook Ask each person to write down their high-risk situation, thoughts, moods and people in their handbooks.

Exercise 2: Relapse prevention planning

This exercise looks at the whole process for coping with each person’s high-risk situation identified in exercise 1. It revises the whole relapse prevention process from stating goals to making plans to deal with a specific situation. It is important to emphasise that managing high-risk situations doesn’t just happen in that situation, but before that situation arises.

How can planning help to avoid and manage these high-risk situations? Ask the group to think what they could do before hand if they knew that their high-risk situation was going to happen. This discussion needs to include:

1. What would need to change in the person’s lifestyle?

High-Risk High-RiskSituation Thoughts High-Risk High-RiskMoods Life situation

High Risk

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2. What they would need to change in their own thinking or emotions that would reduce the risk? 3. How they would fix limits before getting into a situation if they planned moderate use? 4. What could they do to manage their thoughts or emotions that put them at high risk? 5. How could they handle the situation once they found themselves in it? 6. What skills could they use?

Describe how you would prevent relapse in your high-risk situation

In the handbook, write down ideas for preventing a relapse in that person’s high-risk situation (write ideas on the mountain):

1. Describe the person’s Aims, Goals and Objectives. E.g. To remain free from drugs and to use alcohol socially. Manage mental health and stay out of hospital.

2. Described the Changes in Lifestyle that will reduce the chances of this high-risk situation happening. E.g. Changing social networks to non-drug using network. Get a job so less likely to be bored.

3. Describe ways of Changing Thoughts and Emotions that might be associated with the high-risk situation. E.g. Challenging feelings of anxiety or depression make me want to drink.

4. Develop a relapse prevention plan so that you can plan for the high-risk situations. E.g. Plan ways of saying “no”

5. Managing temptation and cravings E.g. Think of a pleasurable alternative to drugs or alcohol if you are tempted

6. Quit early if there is a slip E.g. Planning something to do the day after a high-risk situation or slip so that you do not start using again the next day that could lead on to daily usage.

Ask participants to describe their relapse prevention plan to the group or the person sitting next to them.

BREAK Exercise 3: What skills can we use to cope with high-risk situations?

This exercise looks at the specific strategies that can be used to cope with high-risk thoughts, moods or situations. It invites each participant to decide which skill would be best to deal with that high-risk situation, thought, mood or person. Use the list of skill cards that can help the person revise the skill that can be applied to their particular high-risk situation.

Which skills can help us manage these situations? Ask if participants can recall the skills developed throughout module four of the programme.

Which of these skills would help cope with the high-risk situations, thoughts, moods and people?

Which skill? 1. Divide the participants into pairs. 2. Distribute all the skill cards to each pair. 3. Ask each person to help the other person in the pair to decide which skill they could use to cope

with their particular high-risk situation. 4. Go round inviting as much discussion as possible of each

Exercise 4: Skills role-play

This exercise gives each person the chance to role-play or talk through their relapse prevention skills. Using each person’s high-risk situation, set up role plays for each person using the rest of the group to help them re-enact that scenario. If the coping mechanism is a practical exercise that can be role-played

Describe your high-risk situation Ask each person to describe their high-risk situation again and how they are going to manage it.

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Role play the situation Think of a way of developing a role-play that can practice using the skills described. Use other people in the group as co-actors for the role-play.

If a role-play cannot be used for internal type processes (e.g. mindfullness skill, relaxation) then ask the person to talk through how he would manage his high-risk situation from beginning to end.

Assignment: Review of the programme

This assignment invites participants to look through their handbooks and review the sessions that they have completed so far.

Complete the Programme Evaluation Questionnaire

SESSION 24: Changing Lifestyles and Moving On… INTRODUCTION

This session thinks about how changes in lifestyle can help people move away from using drugs or alcohol and enjoy their lives. It looks at how life without drugs or alcohol can be just as rewarding and satisfying. It also thinks about how we can take more care of ourselves and put our health as a priority in looking after ourselves. It goes on to look at how we can continue to focus on our health and healthy lifestyles after the end of the Drug and Alcohol programme. How can we support each other and continue to keep-up our motivation to stop using drugs or alcohol. Key Issues: 1. Thinking about all of the substances we use (caffeine, tobacco, pain killers, alcohol etc) drugs and

alcohol are an integral part of all of our lives. 2. If drugs or alcohol have played a large part of someone’s life, it can sometimes be hard imagining life

without drugs or alcohol. 3. Whilst it is possible to change our own lifestyles, it can sometimes be difficult to change other people

around us who put us at risk of using drugs or alcohol. Exercise 1: Changing Lifestyles

This exercise uses the imagination to think about how life would be different in the absence of drugs or alcohol. It is important to embellish this scene by imagining that it is in the future or a parallel dimension where no drugs or alcohol have ever existed. Think about all types of drugs and alcohol including tea or coffee and cigarettes. How would we socialise differently? How would society be different? How would we feel about life? What would be different about us? This exercise can raise equal amounts of hope and fear

Close your eyes for a moment. When you open them you will be entering a New World in which drugs or alcohol do not exist…

What do people think would be different between the Old World with drugs and alcohol and this New World?

What would be different in the way people get together and socialise? How would you socialise and have fun? How would participants’ worlds be different? What would replace the function that drugs and alcohol once had? If people are unable to think about how their lives would change without drugs or alcohol, think

about how different their world would be without cigarettes or tea and coffee.

Old Me - New Me In handbook, write down some of the main differences between yourself when you have been using drugs or alcohol (including cigarettes) and your life without drugs and alcohol.

Session Objectives 1. To imagine a lifestyle without using drugs and alcohol regularly.

2. Think about the changes in lifestyle that would help people remain abstinent from drugs or alcohol.

3. Think about how members of the group can support each other in staying off drugs or alcohol.

4. Review the drug and alcohol group programme

5. Get feedback on the programme.

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Exercise 2: Making the Change This exercise thinks about which types of activities are most associated with drugs and alcohol. Generally, social or leisure activities are more associated with substance use. This would suggest that keeping busy and using recreational time would make people less likely to think about drugs or alcohol. This exercise also looks at suggestions for planing the day to avoid high-risk situations. It brainstorms a list of ideas for activities that can either take the place of substance using activities (e.g. the pub) or activities that are incompatible with using drugs and alcohol. It is important not to simply avoid some important areas of life (e.g. relaxation) which may be high-risk but to find activities that have a similar function that do not place the individual at risk of using drugs or alcohol.

What activities can we do that do not involve drugs or alcohol or make us think of using drugs or alcohol?

Think about all the activities within three domains: 1. Work E.g. Getting up early. Travelling to work. Having lunch. Talking to people at work. 2. Hobbies and Exercise E.g. Playing football. DIY. Swimming 3. Recreation E.g. Sitting down and watching TV. Reading. Going out. Meeting with people

Which of these activities would make people think about using drugs or alcohol? Which are the most high-risk activities?

How can you change your lifestyle and plan activities to reduce the risk of using drugs and alcohol?

Think about the activities that are particularly risky (e.g. watching TV and having a drink/smoke) and think about how this activity could be changed or replaced to make it less risky.

Exercise 3: Why look after yourself?

This exercise thinks about the attitudes people have towards themselves that can either help promote or prevent changing to a healthy lifestyle. It looks at some of the difficulties a person can have in caring about themselves and thinking about their health as important. Use the Socratic questioning style to really draw out how mad it is to use drugs or alcohol. It goes on to think about how simple it is to achieve a healthier lifestyle. It is important to emphasis that this lifestyle does not have to be highly disciplined, regulated or self-depriving.

Why don’t we look after ourselves? Does anyone think that sometimes we can be our own worst enemy?

Why do we sometimes do harmful things to ourselves? If anybody else treated our bodies the way we treat ourselves we would sue them for damages. Why is it sometimes acceptable to do things to ourselves that are not good for us? E.g. We do not realise that it is not good for us. We forget that it is bad for us. We convince ourselves that it is not so bad for us. We minimise what we are doing. What’s the point in changing. Helplessness.

How can we make our own health important?

What would need to happen to get people to think about their own health? E.g. Being told that they had problems with their health (too late). Being told that they were going to die. Not being able to do something such as climb the stairs.

How can we start a healthy lifestyle? Ask if participants have ever tried to change to a healthier lifestyle in the past. What types of changes did they make in their routines?

1. Do something good to yourself every day. 2. Eat food that is healthy and enjoyable at least once a day. 3. Get your heart pumping through exercise at least once a day. 4. Relax your mind and spend some time enjoying being alive at least once a day.

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5. Notice the difference in yourself and congratulate yourself for making the changes. Which activities would help to change to a healthy lifestyle?

E.g. Starting to swim once per week How could you adapt your existing lifestyle to make it more healthy?

E.g. Riding bike to work or events rather than taking the bus BREAK Exercise 4: Moving on

This exercise looks at ways the group can help each other stay free from using drugs or alcohol. It looks at how self-help groups can be used to support people and keep them on the right track after the end of the group.

How can this group help each other remain abstinent from using drugs or alcohol? Discuss different ways in which the group can help each other and give each other support using:

1. Drug Free groups These are groups developed for people who want to develop their healthy lifestyles and enjoy themselves without using drugs or alcohol. Different activities can be organised that are not orientated around the use of drugs or alcohol. The group can develop ideas that 2. Buddy systems This is where two or more people team together to support each other and help remind each other of their goals and objectives, their relapse prevention strategies and relapse prevention skills. 3. Any other ideas Ask the group for any other ways in which they can continue to support each other in remaining abstinent from drugs or alcohol.

Community Services

Discuss the types of services that people have heard of. Go through the list of national helplines and organisations and community drug and alcohol services in the handbook. Discuss how they would use these services and at what point they would contact them.

Exercise 5: Feedback

This exercise aims to get verbal and written feedback using discussion and feedback questionnaires. It also congratulates participants for completing this programme and for taking the first steps in staying free from drugs and alcohol.

How did you find the Drug and Alcohol programme? Ask about what exercises or sessions participants: Remembered? Thought were good? Were not useful?

Collect in the Programme Evaluation Questionnaire from the assignment. If participants have not completed this yet, ask them to complete it now

Hand out certificates for completing the Drug and Alcohol Programme Invite participants to the front one by one and give them their certificate and congratulations Assignment: Meet with Primary Nurse or Care Co-ordinator

The purpose of meeting with the primary nurse is to help to give some feedback to the participant in front of the primary carer and to get feedback from the participant about the group. During this meeting, the relapse prevention plans should be discussed and how the clinical team can help contribute to these

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plans. The patient should be able to describe the high-risk situations that place them at risk of using drugs or alcohol and these should be care planned. Participants should also be given the post group evaluation forms and questionnaires to complete.