Relapse Prevention with the Addicted Offender

Welcome everybody. Today we are going to be talking about relapse prevention, specifically relapse prevention in the addicted offender. But as you will see, you know, we're kind of talking about semantics here. Relapse prevention is relapse prevention. So we will define relapse in terms of addiction as well as mental health. As I've said like a bazillion times, and I know you're tired of hearing it, co occurring disorders are the expectation, not the exception. If somebody's mental health starts to relapse, likely that addictive behavior will also relapse as well. So we need to be alert for both of those. We'll examine relapse prevention techniques and explore the needs of the person, those psychosocial needs, as well as Maslovian, like how I created a word there, you know, so let's just get on with it. Relapse is the return to addictive behaviors or the recurrence of mood disorders. So basically we're talking about someone who has been either drug free and not engaging in addictive behaviors. And I'm very specific when I talk with my clients about the difference between being clean and sober. Being clean, you haven't used, you haven't engaged in your addiction of choice. If it's a behavioral addiction, sobriety is a whole set of behaviors. Honesty, hope, faith, courage, discipline and integrity being the top ones that comprise this new lifestyle that run kind of counter to criminogenic and addictive thinking. So relapse is a return to those. But how does it happen so many times? We'll hear, well, this relapse caught me from out of the blue. And this isn't just addiction. This is depression, this is anxiety, this is other stuff. People come in and they're like, I don't know what happened. I was doing well. And then all of a sudden I woke up and I just couldn't get out of bed. And they're kind of scratching their head. And my first thought is, okay, did anything major happen? Extreme stressors can prompt what we would consider like an immediate relapse. And we'll talk about that in a minute. But more often than not, people just get caught up in the day in and day out. I want you to think for a minute about your drive to work and your drive home. Do you remember exactly every stoplight you stop at and exactly every turn you make every single day? Or are you kind of on autopilot? My guess is autopilot. And why do I bring that up? Because this is what we as a society and I'm not pointing out that this is, you know, people who have addictions or people with depression. This is all of us. We tend to get caught up in the day in and day out and start acting what we call mindlessly. And mindlessly is when you leave the office, you get to the house, and you get there safely. But, you know, for the life of you, you can't remember half of those turns that you made. Same basic thing when we're talking about relapse prevention. People get caught up. They get up in the morning, they turn off their alarm, they eat breakfast, they take a shower, they go to work, they do what they've got to do. They come home, they may or may not go to a meeting, and they go to sleep. They get up and repeat. You know, it just becomes this automatic process, and they don't stop to think, am I getting run down and am I getting overwhelmed? Am I getting, you know, kind of fill in the blank? When my children were really little, and it's not as prominent anymore, but I could always tell with both of them before they would start to get sick about a week ahead of time, maybe a couple of days, they would start to become more rambunctious and get what I would call more disorganized. They were just, you know, kind of all over the place, couldn't focus, tired, cranky, which was not normal behavior for them. Being aware of this as a parent, I could say, oh, something's getting ready to go down. They're either getting ready to go through a growth spurt or they're getting ready to get sick. Because 99% of the time, it was one of those two things. Some days they were just having a bad day. But most of the time, when they really started becoming disorganized, there was a reason to it and what our clients do and what we may do. I know I'm guilty as anybody else. We don't pay attention to this stuff. We get up and we make our breakfast, and we start, you know, doing whatever we do and getting into the process. And it's sort of the difference between a 2 cup of coffee and a 5 cup of coffee day. You know, you just kind of push through to get there. And not that I am recommending five cups of coffee. You know, we all have our vices, but when you are getting through the day and you are just pushing through, you are not stopping to go, okay, what's going on? Why am I so fatigued today? This is the mindlessness that people get into. This is the mindset put your head down, push through, get through it. That leads to relapse for both the mental health and the addiction. So people start acting, acting mindlessly. They stop going to meetings, counseling, church or whatever. Their lifeline is to help them stay grounded and focused in their new behaviors, which are not, you know, totally ingrained yet. So we want to ask them, why did you stop going to meetings? Because generally it's like, you know, Jim Bob gets home from a long day at work and it was one of those five cup of coffee days and he's like, I can't, I just can't leave the couch today. I need to take care of me. And he falls asleep and he gets up and he goes back at it again, not looking at what was causing the fatigue, just saying, I can't do what I need to do. So the person begins running out of energy to do these new behaviors. Coping takes a lot of effort, it takes a lot of practice, believe it or not, to de escalate yourself does take a lot of energy sometimes. And for people who aren't used to employing these new behaviors to people who aren't used to doing things clean and sober, it can be really, really exhausting. So then you start cutting corners. Frustration, irritability and exhaustion set in. After you've been running at 120 for four months, not really stopping to think about where you're going, where you came from, what's going on, how you're feeling. You're just doing what you got to do. At a certain point, people generally hit the wall and it's like, I need a break, I can't do it. This is when we're really at that critical point. Relapse started back with the mindlessness when they started getting fatigued and started developing vulnerabilities. When they're at this crisis point, this tipping point, we're right on the verge most of the time of either a full blown depressive episode, panic attack, anxiety, whatever, or going back to using. So you know, there are danger signs, there are warning signs, there are what we call relapse warning signs that people try to minimize or they just don't even notice. Extreme stressors are those things that overwhelm an individual's ability to cope, thrusts people into the fight or flight reaction, and the new coping skills and support resources may not even be considered or only half heartedly. Again, I want you to think back to something. You know, you got the call that someone was in a car accident or some you got laid off from your job or something big really big happened and you know, you were thrown into this immediate state of sort of panic. Did you stop and think, okay, now who can I call? What can I? No. Most of the time people are not stopping to think at this point. They want to get control again because things are out of control. These extreme stressors are almost always examples of when people's control have been totally stripped from them. So they want to get that control back and they want to make it stop right now. You know, I can't. No, we can't go there. So the person's not going to say, well, maybe I should do a cognitive behavioral worksheet or maybe I should call my sponsor or maybe I should, blah, blah, blah. They need to be aware of extreme stressors ahead of time because, you know, life happens. I'm sorry it stinks sometimes, but it's going to happen. We can't shield them from these things, but we can provide them the opportunity to be able to handle the overwhelming stressor better. And how do we do that? Practice in group or in session with different types of losses that the person might experience. And if you're doing an individual session or maybe even a group, you can ask people, what do you think are some things that could happen to you that would just completely throw you into a tailspin? Write them up on the board or on a sheet of paper, then start practicing one at each session. What would happen if you were served divorce papers? How would you feel? How would you de escalate yourself? What would be your first step in handling this? Walk them through. Have them imagine this happened. You know, sort of systematic desensitization. Imagine this happening. Have them work on slowing down their breathing and figuring out what they're going to do next to get out of that sort of emotional reactive state of mind and into a more practical mindful state of mind. You know, the four biggest ones. Divorce, death, job loss, or diagnosis of a terminal or chronic illness. You know, cancer is not always terminal, but it can be kind of chronic. You're going back, you're looking for remission. You're looking for when it comes out of remission, hiv. You're getting your T cells counted all the time. You're looking for different signs there. You're looking for opportunistic infections. So there are a lot of things to deal with. And we actually have a series of classes coming up on working with the patient with HIV and working with the families of patients newly diagnosed with hiv. So beginner tools for extreme stress. Get support. You're outnumbered. What this Was one of the first things that I learned in my internship. Way back when I was talking to one of my supervisors and he's like, I would never do individual counseling with an addiction. I mean, I thought the world of this person. He was brilliant. And I'm like, why in the world would you not do an individual art? He said, because I'd be outnumbered. And I, you know, looked at him quizzically, kind of like that look your German shepherd puppy gives you. And I said, what? And he said, when you're dealing with an addict, you've got the sober person and the addicted person both inside the same brain, and they're both talking to the human person at the same time. Put it in Freudian terms. You've got the id, the ego and the superego all kind of talking together. So you want to have somebody get support because when they start to be under extreme stress, their sober self is now being challenged by their addicted self, or their healthy self, if you will, is being challenged by their self that is dealing with depression or addiction or, or anxiety. Those old thinking patterns, those cognitive distortions, those, well, see, I told you so's are going to come and there's going to be sort of a battle inside their head. They need to get support. They're outnumbered. So as soon as something big happens, or even not so big, we want to encourage our clients to get used to reaching out, reach out to someone. Now for some of our clients that may be reaching out to their higher power first, and, you know, that's fine. Whatever it is that can help them de escalate and get out of that reactive frame of mind so they can think mindfully, be sort of in their wise mind, if you will. They need to figure out how to get support. One of the things I tell people is to keep three numbers on speed dial on your phone. You're not going to want to have to look somebody's number up. You're not going to want to have to remember who was it that I said I could call. Keep them on speed dial on your phone so when something stressful happens, you can call them. Self soothing and de escalation. They're kind of go together. Before people can start making good decisions under extreme stress, they need to get through that adrenaline rush, get out of the haze. So what can they do? And what I would do with a lot of my clients is I say, what helps you calm down? Is it going on a walk? Is it, you know, try to find some productive behaviors? Eating a gallon of Ben and Jerry's not the most productive. So we want to ask them, what is it that helps you calm yourself down? For some people, it may be taking a bath. A lot of times getting those big muscles moving because your heart rate in that fight or flight reaction, if you're sitting still, your heart rate's still going to go kind of through the roof because your body's preparing to fight or flee. Either one requires energy. And if you're sitting still, your mind's going, wait a minute, why is the heart going so fast if the body ain't moving? I'm not getting this. So one of the things that helps a lot of our clients and ourselves is to move these big muscles. Walk around, do push ups, do sit ups. If it's your thing, punch a punching bag. Something soft where you don't cause harm to property or self. These are all options that people can explore. Talk to their dog. You know, I know it sounds weird, but petting an animal helps reduce your blood pressure. And there's a lot of good things about petting an animal if it happens to be handy. Systematic desensitization practice with people. And this is what we talked about on the last slide. Practice having them imagine being in a super stressful situation. I can think of a couple right off the top of my head that, you know, I am exposed to on occasion. And as I think about them, I can sort of feel my stress level going up. So walk them through however you find it most effective to do with your clients, walk them through calming themselves down when they start thinking about the situation. And then ask them how they're going to remember to do this when the situation actually occurs. Cognitive behavioral. I'm big on note cards and I know with the iPhones and everything, note cards are a little bit passe. You can keep them on the little notepad on your iPhone, you know, sure, fine. Or take a picture of a note card. Couple basic questions. Have people, when they get upset, after they've calmed themselves down a little bit, say I feel angry, upset distressed because this is happening. Have them ask themselves, what is it exactly that I'm upset about? What are the facts for and against this belief? So if I feel stressed, angry because I was just laid off, what am I upset about? Well, the fact that I no longer have a job and I don't know how I'm going to pay the rent now. So what are the facts for and against this belief? You know, am I catastrophizing this? Am I using all or nothing thinking or jumping to conclusions? I'll never get another job. I'm going to lose my house. The kids are going to hate me. Me. No. So we want to have people look at the facts and then look at whether they're using some of the most cognitive, most common cognitive distortions. And then finally I need to call one of these support people to get an objective perspective. If they can't call that person. You know, it's not always practical to just pick up the phone and call. Hopefully it is, but not always ask themselves. You know, I can ask myself, what would my daddy do? You know, he was one of those people who just didn't get flustered, he got upset. But he would go into that mindful place really quickly and he would fix whatever it was, he would get it done. So I would ask myself, you know, what would he do? That not only helps the person get out of this spiral whirlwind of negative thinking, but it also gives them some perspective and lets them step outside the situation and take a look at it. So it's five pretty simple questions. The benefit being it gets them outside themselves. It takes some time to help that adrenaline go away. While they're answering this, they're de escalating whether they know it or not. And they're also using some cognitive behavioral tools now that we have the extreme stress and the things that might cause what we would think of maybe as an immediate relapse. Psychosocial needs are those tasks that must be accomplished or needs that must be met as people grow up and as they continue to live. And I'm going to kind of put a little twist on Erickson's theory because I think as we get older, you know, we may have learned when we were children, you know, itty bitty in diapers that people were trustworthy, our feelings were trustworthy, and everything was great. We passed through that trust mistrust stage, no problems. Twenty years later, the world kind of falls apart for one reason or another. And the person may start thinking, well, maybe my intuition isn't right. Maybe what I'm thinking is wrong all the time. So they may revisit that stage and start thinking, well, I really can't trust myself or anyone else. So there are some times in counseling where it meant the psychosocial task may have been resolved maybe very adequately throughout development, but then something caused the person to revisit it and question the conclusions they came to. So anyway, these tasks help people learn self control, confidence and self esteem. Problems in achieving them can lead to problems in development and, you know, just basic living and unhappiness problems later in life may cause people to question earlier conclusions. So it is my assertion that these tasks are not linear and final, we may revisit them. Part of the treatment process is helping people learn how to parent themselves. And I don't really like that word, but I don't know any other term to use because as we go through this developmental process that Erickson proposed, our parents are the ones that kind of serve as the gatekeepers and the the ones that help help us solve the task, solve the problem, solve the challenge. Once you're older, your parents aren't there to do it anymore. Theoretically, you've developed the skills to do it yourself. If you don't have these skills for one reason or another, or if something challenges these skills, you may have to kind of jump into that role of parent as well as self. Clinicians initially take the part of a parental figure, modeling how to resolve issues. So with a lot of our clients, at least a lot of my clients who'd been using since they were 12, 14 years old, part of my job was to basically help them go through those stages again in their new self, with their new identity. And if you can see, I'm using little air quotes. So the first stage is trust versus mistrust. If people receive consistent, predictable, reliable care, they'll develop a sense of trust and faith in themselves and others. So let's think about this in terms of treatment or in terms of life. If an adult provides him or herself consistent, predictable, reliable self care, they learn to have a sense of trust and faith in themselves and in their intuition. When we're on autopilot, we're not providing ourselves consistent, predictable, reliable care, and we start questioning our intuition. Am I sick? Am I just bored? Am I this? When we're talking about other people, if you are regularly bombarded with significant others who are inconsistent, unpredictable, and unreliable, then you may start to think, well, you know, gee, maybe my thoughts about the world being so super trustworthy wasn't quite on par. We want to help people figure out that there are consistent, predictable and reliable others. And it is their obligation to themselves to consistently, predictably and reliably be in tune with themselves to identify what they need. They can't always get everything that they need at that very moment, but if they know what they need, then they can go toward it. An example of a need versus a want, if you will. When we talk about infants, we talk about, sometimes we talk about parents who, you know, don't understand that infants have different cries that have different meanings. So every time the child cries, it gets a bottle in the mouth. Maybe it was hungry, maybe it was scared, maybe it was tired, maybe it was wet. But the message that it got was, you're hungry. Fast forward to later life. If someone consistently, when they're tired, stressed, whatever they eat, that's not consistent, predictable, reliable care, they. They are not listening to what their body's telling them they need. They're just trying to sort of pacify it, if you will. If or when we help them figure out how to listen to themselves, do what they need to do for them, and surround themselves with healthy others, they'll develop a sense of hope that as new crises arise, there's a real possibility that other people are going to be there for support, and they'll have the strength to endure whatever's going on and know their intuition is correct. The I can get through this, or what I need right now is what we want is phrases coming out of our clients like, I can trust myself. I can trust my thoughts and intuition. Instead of them starting out with something like, well, I might be crazy, but no. If your intuition, if your spidey senses are telling you that something is not right, let's talk about why you think they're going off. Because likely they're somewhere. There's some kernel of truth in that, and I can trust those around me. Remembering that a lot of our clients go for the dichotomous thinking when they start to say, I can't trust anyone. We want to help them identify exceptions, and we want to help them nurture relationships with people who are more supportive and are more available to them. An example I would give you of going back to this trust versus mistrust. A child abuse survivor may need to learn later in life to trust people again and trust their own intuition. If they were abused by a caregiver, that may have been very confusing because that was someone that they were told they were supposed to be able to trust, someone that would not hurt them. And then, you know, all that happened. So we want to ask people or encourage people to look at what's going on now. You know, who can you trust? Let's learn to trust your intuition now. When you were 18 months old, when you were 3, there were a lot of other factors that played in. Who can you trust now? Do you need to deal with the issues back in the past? That's up to your philosophical approach. As far as relapse prevention is concerned, we need to focus on the here and now. Autonomy versus shame and doubt. So we want to help people explore the limits of their abilities with an encouraging environment, which is tolerant of failure. And I went on my little soapbox last class. I'll minimize it this time. We want to make sure that when people have a setback, maybe not a full relapse, maybe not even a slip, but a step back, set back, we don't come at them with a critical tone going, well, why did you do that? Let's look at, okay, so tell me about what happened and how we got to this place. We want to welcome people back in. We don't want to say, well, you relapsed, so you need to be transferred to a higher level of care. You know, giving you the boot, can't deal with you anymore. That doesn't give people a sense of security. Now, true, they may need to be transferred to a higher level of care, but that comes later in the conversation. Let's start out first with, I am so glad you came back. Let's talk about what happened and what we. What the next step is that we need to do. The same is true with anxiety or depression, especially depression, because people, when they start to get depressed again, you know, they're feeling pretty good and that depressive episode comes in again, they may not come back to treatment. So if they come back, we don't want to start going, well, what did you do to make it come back? We want to say, awesome for coming back. Let's talk about what we may have missed. The aim has to be self control without a loss of self esteem. Remember talking about criminogenic behaviors? Over the past few weeks, we've talked about a key issue in criminogenic thinking and criminogenic behaviors is a loss of self control. They don't have the ability to delay gratification. They have this immediacy. I want it, I want it now. I don't care who I have to go through to get it. So success in this stage leads the person to the virtues of will, discipline, and courage. So they're taking chances here. They're putting themselves out there. You know, maybe they're trying to go back out and get a job again. They haven't had a job in a while or they're going to support groups and they've never been to one. So we want to encourage them to get outside their safe zone just a little bit. And if they have to come right back in, that's okay. At least they tried. We want them to have the courage to be able to go out and try and feel like they can come back if it doesn't feel so good. We want to have them, encourage them to have the discipline to keep trying to not give up and say, oh yeah, I didn't like that. I'm just going to stay in my comfort zone henceforth and forevermore. If people are criticized, overly controlled or not given opportunities to assert themselves, they may begin to feel inadequate in their ability to survive. Okay, so think about a lot of treatment centers, think about a lot of families, especially the ones that are overly enmeshed. Where people are criticized and controlled, everything they do is wrong. You need to do it this way, you need to do this and not that. If every time a person tries something they receive, even if it's presented as constructive feedback at a certain point, the person may just be like, really? I can't do, why don't you just do it yourself? Because I'm clearly not going to do it in a way that makes you happy. Now when we're talking about living their life and they're saying, well, why don't you just live my life for me? Because I can't do it in a way that makes you happy. You know, that's when people end up in therapy. So the person may become overly dependent on others, feeling like, I can't do anything right, so I need people to take care of me. Which often leads to a lack of self esteem and a sense of shame or doubt in their own abilities. Initiative versus guilt. People learn to initiate activities with other and feel secure in their ability to lead others and make decisions. One of the biggest early hurdles in recovery, whether it's from severe and persistent mental illness or addiction, or engaging with a new peer group, once a person is paroled from prison or jail, is learning how to initiate activities and feel confident about it, you're joining a whole new peer group. And for people in recovery from addiction, they're joining a whole new peer group and they're sober. This is really, really scary. So we want people to kind of start dipping their toe in and early recovery, getting used to engaging in recreational activities without being wasted and being okay, laughing at themselves. As clinicians, we want to model this. You know, I laugh at myself a lot and you know, my point is that I'm not perfect, you're not perfect, they're not perfect, but that's okay. And sometimes we do stuff that's really bonehead and that's okay too. Just laugh at it and move on. Six hours from now, let alone six months from now, people probably won't remember it we don't want to squelch their tendency to try to make plans and initiate activities. We may want to encourage them to think about how much they're going to bite off before they start doing it. I've seen a lot of people get really involved in 12 step organizations and start wanting to host their own meetings before they even get out of treatment. I'm like, okay, slow down, slow down. Let's back up and take a look at what could you gain by continuing to watch for another six months. I don't want to tell them not to do it, but I do want them to go in it with their eyes wide open. A healthy balance between initiative and guilt is important. We want them to take reasonable chances. We don't want them to go out and just be like, I can conquer the world. We want them to take small baby steps outside their comfort zone, feel successful in it, and then grow from there. And as we move on. Industry versus Inferiority. The people's peer groups are becoming a major source of self esteem. Now remember, whether you're dealing with somebody who is just getting out of jail, somebody who is in early recovery, or somebody who has been dealing with chronic major depression or severe and persistent mental illness for a while, their peer group is probably going to change somewhat because in all three cases, a lot of times the healthy, supportive peer group has dwindled over the years for one reason or another. So now they're integrating into a new peer group and sort of having to do that whole identity thing all over again that a lot of us did. You remember when you went to high school and how horrible it kind of felt sometimes integrating into this peer group and trying to figure out who you were and wanting to be accepted. People feel the need to win approval by demonstrating specific competencies that are valued by society or this particular peer group. So they want to demonstrate that they're clean, that they're sober, that they're happy, that they're this, that they're that it can get overwhelming for the person in recovery. And one of the things that I come back to for all of my clients, that they need to win their own approval first. I don't want them to rely on external validation from these peer groups because as they feel confident in themselves, as they have their own approval, they will attract positive people into their life through the activities that they do and through the things that they do. We don't want them to doubt their abilities. We want them to go out and try. Some failure may be necessary so the person can develop an Awareness of their personal limits. We don't want them to think that they've got the world by the tail the minute they walk out of treatment. We want them to be realistic. You finished treatment, that's a huge accomplishment. You've been clean and sober for 30 days. That's a huge accomplishment. But being clean and sober in a controlled environment, whether it be a hospital, a treatment center, or jail, is far different than being clean and sober in a very uncontrolled environment. So we want people to be aware of the challenges that they might be facing so they can plan for them and deal with them as they come up. Throughout this process, they're developing a new, happy, sober social identity. They may experiment with different lifestyles. I have had clients that, you know, pretty much came into treatment with a certain lifestyle, a certain attitude, a certain whatever, and leave with very much the same just some adjustments in their thinking styles and their coping skills. But I've had other clients who have just done a complete 180 and they've come out of treatment and they have, you know, become very Zen in their recovery. We want to encourage people to find what's going to work for them. A lot of times we have people come into treatment that are very, very angry at their higher power in the world. Those same people may actually end up leaving treatment. Some of the most devoted to their higher power. I don't want to question or squelch that. I want to encourage them to figure out what path they want to be on. Pressuring someone into an identity can result in rebellion, though. This is where my little this is today soapbox. Pressuring someone into a specific identity, saying, you have to have a higher power. That's not going to go so well with everybody. So we want them to figure out what their identity is, what is their sober identity, who do they want to be? What do they want that to look like? And then as clinicians and as, you know, sober social supports, we can provide them feedback on how to move towards those goals if they need feedback. Otherwise, we could just provide support as they do it on their own. And then intimacy versus isolation. And I kind of stopped here because a lot of people's major depressive episodes or addiction or criminal behavior starts midlife or before. So looking further, those are just other issues that aren't going to be as prominent. But in intimacy versus isolation, sharing ourselves and being accepted and loved for who we are. I want you to take a minute and think about, you know, 10 of your clients. Well, let's do five, because we don't have a lot of time. How many of them have actually shared themselves? I mean honestly shared themselves and been accepted and loved for who they are by more than maybe one person. And you know, let's take out parents and children and even sometimes parents are not providing of unconditional positive regard. So we have a lot of people who've never experienced, experienced this. So they don't know how to love themselves, accept themselves for who they are. Which leads to. You got it. Searching for external validation. If somebody is searching for external validation, they need others to tell them they're okay. The other end of the spectrum is people who just avoid other people. They avoid intimacy, they fear commitment and they just don't want to go there because it's too painful to go, it's too unpredictable. It's not something I can control. So I'm just not going to go there. Exploring past relationships is a task for therapy. Relapse prevention, you know, and again, relapse prevention you can almost think of as coaching. We want to increase awareness of what healthy relationships look like. So what are these relationships that you want to develop? So many of my clients over the years have had no boundaries at all. So they get into a relationship and within two weeks they're like moving in with somebody and I'm like, wait, wait, wait, you just met them. So how did you get from him buying you drinks in a bar to moving in two weeks later? So we want to look at healthy relationships. We want to look at, you know, emotional boundaries and how much we share and reciprocal disclosure and all that kind of stuff. Things that we just take for granted that people learn throughout their life, but in reality, most people actually don't. It's not something that's taught in health class. We want to remind them, to remind themselves that what happened in the past with a different person is not necessarily going to happen again. So that whole transference thing, if you expect that someone you get into a relationship with is going to be exactly like your ex wife, you're probably going to create a situation where that happens so we can talk about self fulfilling prophecies and transference. I don't want to say that it's not going to happen again, but I do want to encourage people to be able to stop and step back and go, okay, am I upset about this situation or is this reminding me of something in the past that I need to deal with with my therapist next week? So like I promised, moving on. Maslow loved the Maslow. Maslow's hierarchy. It was that Big triangle. The bottom level was biological needs. How does this relate to relapse prevention? Really? Because, and you know, if you've done any training with dialectical behavior therapy and just, you know, pretty much any body mind philosophy, we know that if you've got someone who's not getting their foundation needs met, their biological needs, it's going to be real hard to work on the other stuff. If they don't have housing, they don't have food, they're not getting enough sleep, and they don't have access to medical care, you're going to have a hungry, homeless, tired person who doesn't really care a whole lot about doing self esteem inventories. You know, that's the last thing on their mind. So housing with any of our clients. Depression, anxiety, addiction, criminal behavior, how can they make the best of what they have? Because they may not be in the perfect living situation, they may not be able to get out of it. So we have to say, okay, how can you make the best of what you have? First, let's look at safe routes to and from work, school, wherever you're going. This is especially true for people just getting out of jail and with addictions because there are a lot of people, places and things that lurk around old routes. The next thing is to look for triggers, especially in their home or room. And this is true for anxiety, depression, anything. What triggers dysphoria in this person, what triggers the desire to use, what triggers the desire to engage in criminal behavior? What things are there? One of the first things I have, all of my clients do is either change their phone, ideally change their phone number completely. That way their old dealers can't get hold of them. And if they are involved in criminal justice, they're old running buddies, can't get in touch with them. So getting rid of that so you don't have the peer pressure coming in, looking around the room, are there pictures? You know, if you've got a big old poster of Bob Marley on the wall, you have to ask yourself, is that going to be a trigger for use? Is that going to be a trigger for something? For some it may not be. For the majority it probably will be. So looking around and sanitizing, if you will, the room, but also putting in triggers or reminders of positive things, pictures of their kids. In our treatment center we used to have, you'd go into the, into the dormitories and people would have pictures that their kids had drawn for them and pictures of their children thumbtacked up on the cork boards behind their bed. Something they could look at and feel happy about as they were going to sleep. Have them make collages, have them put other things up that make them happy. I have a. You know, formal tapestries can be really, really expensive, but you can get the throw rugs or throw blankets that you, you know, put over a couch or something that have words on them. And I have one that has the serenity prayer on it, and I put it on a. On a hanging rod and I have it hanging as a tapestry in the corner of one of my rooms. So whatever it is that helps them feel calm and helps them stay grounded in their recovery focus. You know, obviously if you're dealing with mood disorders, there may be other things that the person wants to put up or to look at. The other thing to look at, especially with mood disorders, is lighting and color. Daylight spectrum lighting and lighter colors. We don't want somebody who's really depressed in a navy blue room, unless that's just really, really what they want. I'm not going to tell them no. But we might suggest maybe having a focus wall that's navy blue, having other walls that are potentially a lighter color. Anyhow, have them evaluate what are the negative and positive triggers and solutions in their current environment. What are the negative people and how can you deal with it? Who are the positive people and how can you get more of them? What are the challenging times of day or week for you? How can you deal with it and what are the best times of day or week for you? Maybe Saturdays are the days. You know, in our house, Friday evenings we do a family movie thing. So I love Friday evenings. That's a time of day that I can look forward to. So that's something I can focus on looking at what makes people happy in addition to what makes them happy, you know, a little bit stressed and identify trigger things in the environment. I talked about the poster of Bob Marley earlier. Having alcohol in the house, having tobacco in the house. If you're dealing with somebody who also has binge eating or food issues, maybe there are certain types of foods that they would prefer not to have easily accessible in the house. Whole other lecture on. On eating disorders and binge eating. But what is it that can make your house feel safe where you're not going to easily relapse? Medical care. This is one of those vulnerabilities. Chronic pain. I know when I'm in chronic pain, you know, if I've hurt my neck or, you know, done something to hurt my back or whatever, after 40, everything starts to fall apart. I think, but I can get kind of cranky. Not only can I get cranky, but I may not be able to get good sleep because I can't get comfortable. So I'm already cranky. I'm not getting good sleep. And then life happens and it gets a little bit stressful. My tolerance for stress is a lot lower if I haven't had good sleep and if I'm in pain. So we want to try to eliminate this. This is just a vulnerability that sets people up and makes them more prone to. To relapsing. Mental health. Keep it under control, encourage people to recover and recreate. Too often we think that if we're going along and getting along, we're doing just fine, but we need to take time to rest and recharge. And substance abuse. Now, obviously treatment is good. Not abusing substances, great. If somebody needs additional assistance, talking with their doctor about medications that can help them deal with the cravings or prevent them from using. Our other alternatives, medication assisted therapy are other alternatives, especially in early recovery. And food, water and sleep, I kind of lumped those together because these are all things your body needs to recover, whether it's to balance out those neurochemicals so you're not feeling as depressed or to help you get through until the SSRIs kick in, or whatever the case may be, or to help the body recover after, you know, 20 years of using methamphetamine. People need food, water and sleep. Food gives you the building blocks, water flushes the toxins. And sleep gives your body time to focus on recovery. Which takes me to routine, routine, routine. Believe it or not, serotonin is involved in sleep. And there's a lot to be said for getting your circadian rhythms in order. People who are sleep deprived have difficulty telling the difference between anxious, angry, hungry and sleepy. They've actually done studies and found that because they just feel icky and bleh. Love those clinical terms. So helping people get some sort of a routine. We'll be doing a presentation on sleep hygiene in a couple of weeks. And one of the easiest things for people to address, you know, it's not like they have to tell me their deep, dark secrets. We can just talk about sleeping and paying attention to what and why they're eating, and they start to feel a little bit better. Imagine that you're not eating as much crap and you're feeling pretty good safety. This is the next layer from physical or psychological injury by self or others. Too often we think of safety as, well, keep somebody from attacking me well, that's true, but for a lot of our clients, they are their own worst enemies. The things they tell themselves they would never dream saying to another person. So when we talk about, you know, what kind of self talk did you have when that happened? You know, my first reaction is usually, is that something you would say to your best friend or your daughter or your son? And most of the time people's eyes get really big like, no, I would never say that to somebody else. I'm like, well, why are you saying it to yourself then? Why don't you deserve the same respect that those people do? And you know, we talk about it, and after we talk about it the first time, as soon as I say, is that something you would really say to your best friend? They're like, no. I'm like, okay, so what? Let's look at it and talk about what constructive self feedback might have looked like. Relationships. Helping people develop nurturing but not enmeshed relationships that encourage sober behaviors. And what we're talking about is very simple. I'm not necessarily talking about going to meetings or, you know, anything in particular. I'm talking about being honest with self and others, having hope. You know, if you feel hopeful, you're going to want to get out of bed. Having faith in yourself and other people, courage to get up out of bed and do the next right thing, and the discipline and integrity to know what the right thing is for you. I mean, we all have some ethical differences here and there, but this is what we want to talk about. We don't necessarily want to pigeonhole people into a certain very limited set of behaviors. I want to know what works for them, to help them embody these characteristics. And then I want them to surround themselves with nurturing others that also embody those characteristics. And finally, self esteem, a sense of pride in who they are. Acceptance of their strengths and weaknesses. Being able to say, you know what? I'm not perfect. My son is getting ready to take a college math exam, and math has never been my strong suit. Decent with statistics and, you know, financial math. I can balance my checkbook and stuff, but once they started adding letters and Greek characters and stuff, I start drooling on myself. So, you know, I am the first one to admit that I am not good in math. Matter of fact, I think at it. And that is just one of my weaknesses. And you know, we kind of joke, we kind of joke around our house sometimes and I'll do something completely silly and my daughter will look at me and be like, you know, some days I wonder how you got that PhD. I'm like, just go upstairs and do your homework. But understanding that and being able to laugh at ourselves and go, yeah, you know, that was not one of my more shining moments and move on. And it's okay. I am okay as a person. I don't have to be good in math. I don't have to, you know, be the sharpest tack in the toolbox all the time. So we want people to feel this so they don't need to seek external validation if they're seeking it. Oftentimes it's frantically. And frantically seeking external validation usually leads toward people who are not having your best interest in mind. With that, you know, kind of little segue here, I challenge you to watch the movie Pinocchio. Pinocchio pretty much embodies addiction. Jiminy Cricket is obviously their sober selves and you know, Pinocchio falls in with a bad crowd that don't have his best interests at heart. So it's a really interesting treatment movie where people can identify who was there and who wasn't without. And it's more playful, I guess it doesn't feel as condemning. We want to eradicate harsh self critical self talk. You know, let's figure out what we're good at and let's figure out how to accept what we're not good at. You know, you can't change. Well, sometimes you can change it. I could probably go back and learn calculus now, but I don't want to. It's not worth my effort. We want them to get to the point to go, you know, that's okay. I am okay without knowing what the alpha coefficient is or whatever. There are a ton of self esteem workbooks, so I'm not going to go over a bunch of those. And that helps build the self esteem, build upon what we hope would be there. But we also need to eliminate that negative self talk and be aware of the imposter phenomenon. So we don't talk about this enough, but people will start to feel, you know, they get a job, they feel important, they feel like they're all that, or they portray that. But then there's this little voice in the back, in the back of their head going, you realize you're a fraud, right? We need to shut that voice up. But people can be very vulnerable to the imposter phenomenon in early recovery as they're trying on this new lifestyle, this new identity. They've tried it on, it fits good. They're doing the next right thing and then they start to remember the prior 20 years. And they're like, you're a fraud. So we need to help them deal with that negative voice. Relapse begins when mindfulness ends. Mindfulness means being aware of who you are, how you feel emotionally, mentally, and physically, what you want versus what you need. You may want a chocolate bar, but what do you need? Are you eating, for example? Are you eating because you are hungry or stressed? We want them to figure out what they need. And what does not getting these wants met mean to you? If you can't have this, what does that mean to you? For mindfulness, I have my clients complete morning and evening journals. Yeah, both how they feel when they get up in the morning, then how they feel at the end of the day. They're quick, fill in the blank journals. It's not some big thing. If they want to do a long journal, a prose journal, more power to them. But I do want them to hit the highlights of how they're feeling and involving behavior, interruption, especially regarding substitute addiction. So if they can't get to whatever it is right away, you know, don't keep alcohol in the house. Can they go out to a bar or a store and get it? Yeah, but that's going to require getting out of their PJs and driving across town. Is it really worth the effort once you put that time stop in there? A lot of times people can kind of get control of what's going on and what they really need versus what they want. And the mindfulness matrix. This is the last slide, I promise. And there's a link in the class for Kevin Polk's video on how he explains it. But basically, the top is your five senses experiencing how you see it, hear it, touch it, sometimes taste it. The bottom is mental experiencing what you think about it. And we want people, whenever anything happens or they're getting ready to make a decision, you want them to ask themselves, is this moving them toward happy sensing and happy mental experiencing or away from it? And once they get the hang of it, it's a really quick tool that they can employ. You know, driving in traffic, it's not like something they have to sit and chart and write down and everything. Is this getting me closer toward where I want to be emotionally, mentally, and physically? Or is it moving away? Is it helping me hide from something that's going on? Relapse prevention begins with remaining aware of your wants and needs. Relapse begins when the old behaviors start to surface, such as avoidance, minimization, rationalization, denial, and numbing. People need to learn how to self govern as part of recovery. And they need to learn how to meet their basic needs and understand how these needs impact their recovery because that'll keep them motivated to do it. 1:00 clock on the nose. Are there any questions? Okay. If anybody thinks of any questions, you can go ahead and email.