Addiction Recovery

Addiction in the U.S.

• Current statistics show more than 50 million addicts
• An estimated 8-10% of the US population are sex addicts
• 17 million people are heavy drinkers
• 8 million people need treatment for illicit drug use
• 6 million people have serious gambling problems
• About 10 million people have eating disorders
• 70% of all violent crime, 90% of all poverty crime, 50% of homicides, 50% of traffic fatalities, 50% of fires and 33% of all traffic accidents are directly related to people abusing drugs & alcohol
• Many suicides are addiction related
• In 2004, drug addiction alone had an economic/societal cost of about 200 billion dollars

Research of addicts active in their recovery shows:

• Crime related costs drop by $8,600 per recovering addict
• Absenteeism from work decreases by 92%
• Tardiness to work decreases by 89%
• Problems with job supervisors decrease by 56%
• Mental Healthcare costs decrease by 36%
• Days in the hospital decrease by 25%

"Recovery" means: to bring back to a normal position or condition; to find or identify again; to save from loss and restore to usefulness.

Stages of Addiction

Many different organizations describe the stages of addiction for a particular substance or behavior. For our purposes, we'll look for common denominators for all five addictions we address in this introduction. The stages are use, misuse, abuse, dependence and addiction.

Use - A married couple enjoys their sex life, a woman takes her pain medication as the doctor prescribed, we all enjoy eating, we might make a small bet with a friend, and we all are happy to help people who are in need. In this stage, people use substances and enjoy behaviors responsibly with no painful consequences.

Misuse - In this stage, people begin to experience negative effects of their choices in their relationships, work and health. A man occasionally views pornography, but he hides it from his wife. A pattern of deception begins to develop. A woman may look in the mirror and decide her body isn't what she wants it to be, so she skips lunch a few times. She loses a few pounds, even though her weight was already in the normal range. A man bets more than he can afford to lose. A teenager tries an inhalant with a friend.

Abuse - When people continue using a substance or practicing a behavior in spite of negative consequences, they are in the abuse stage. They are no longer deceiving only those they love; now they are deceiving themselves. The woman taking too her painkiller to get high rationalizes that she "has to have it to keep her pain under control." The sex addict becomes obsessed with orgasms and fantasies. The young woman now believes that she must have the same body shape as the models in the magazines, so she begins to exercise two hours a day, and she skips many meals. A man is lonely, but when he eats, he feels better about life. On nights when he feels particularly disconnected from others, he eats a whole pie and a box of cookies. In this stage, family members know something is wrong. Some of them avoid the person, but the compassion of others causes them to worry insatiably about the person who's wrecking his life.

Dependency - In this stage, the substance or behavior is the focal point of the person's life. Money, time and relationships now exist only to provide the drug, pay for the prostitute, get a slimmer body, eat more food to feel warm inside, or get enough money to win big and get out of debt. If substances are used, those using them develop a physiological tolerance. Now, more and more of the substance is needed to get the same feeling. Though their behavior is now having clearly negative effects on them and others, they rationalize, excuse and minimize the problems. Caring family members now are truly alarmed by the behavior of those they love. Sometimes they yell and demand change, and other times they remain quiet and hope the problem will just go away. When they can help the wayward person, they feel indispensable and powerful, but when they fail, they feel deeply ashamed. Gradually, they develop a compulsion to fix the loved one's problems. All of family life revolves around the person abusing substances or behaviors, but they try to avoid the subject like the plague!

Addiction - A person becomes addicted alcohol and drugs when stopping their use causes withdrawal symptoms. The effects of tolerance now means they have to drink far more and use more or stronger drugs?not just to get high, but to prevent tremors, nausea, anxiety and seizures. For addictive behaviors, such as sexual addiction, compulsive gambling, overeating and codependency, the "drug" that keeps the person high is adrenaline. They are on constant alert, compulsively seeking the behavior and defiantly insisting they have no problem at all. In this stage, the life of the family is consumed the addicted person's choices and behavior, and others' needs are often overlooked and neglected. Family members plead and threaten in attempts to control the person who is clearly out of control. In response, the addict often makes dramatic promises to change, but after a few days, things are back the way they were-miserable and confusing.

Alcohol Abuse

Alcoholism: Getting the Facts
For many people, the facts about alcoholism are not clear. What is alcoholism, exactly? How does it differ from alcohol abuse? When should a person seek help for a problem related to his or her drinking? The following information explains alcoholism and alcohol abuse, the symptoms of each, when and where to seek help, treatment choices, and additional helpful resources.

A Widespread Problem
For most people who drink, alcohol is a pleasant accompaniment to social activities. Moderate alcohol use-up to two drinks per day for men and one drink per day for women and older people-is not harmful for most adults. (A standard drink is one 12-ounce bottle or can of either beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits.) Nonetheless, a large number of people get into serious trouble because of their drinking. Currently, nearly 14 million Americans- 1 in every 13 adults abuse alcohol or are alcoholic. Several million more adults engage in risky drinking that could lead to alcohol problems. These patterns include binge drinking and heavy drinking on a regular basis. In addition, 53 percent of men and women in the United States report that one or more of their close relatives have a drinking problem.

The consequences of alcohol misuse are serious-in many cases, life threatening. Heavy drinking can increase the risk for certain cancers, especially those of the liver, esophagus, throat, and larynx (voice box). Heavy drinking can also cause liver cirrhosis, immune system problems, brain damage, and harm to the fetus during pregnancy. In addition, drinking increases the risk of death from automobile crashes as well as recreational and on-the-job injuries. Furthermore, both homicides and suicides are more likely to be committed by persons who have been drinking. In purely economic terms, alcohol-related problems cost society approximately $185 billion per year. In human terms, the costs cannot be calculated.

What Is Alcoholism?
Alcoholism, also known as "alcohol dependence," is a disease that includes four symptoms:
Craving: A strong need, or compulsion, to drink.

Loss of control: The inability to limit one's drinking on any given occasion.

Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, occur when alcohol use is stopped after a period of heavy drinking.

Tolerance: The need to drink greater amounts of alcohol in order to "get high."

People who are not alcoholic sometimes do not understand why an alcoholic can't just "use a little willpower" to stop drinking. However, alcoholism has little to do with willpower. Alcoholics are in the grip of a powerful "craving," or uncontrollable need, for alcohol that overrides their ability to stop drinking. This need can be as strong as the need for food or water.

Although some people are able to recover from alcoholism without help, the majority of alcoholics need assistance. With treatment and support, many individuals are able to stop drinking and rebuild their lives.

Many people wonder why some individuals can use alcohol without problems but others cannot. One important reason has to do with genetics. Scientists have found that having an alcoholic family member makes it more likely that if you choose to drink you too may develop alcoholism. Genes, however, are not the whole story. In fact, scientists now believe that certain factors in a person's environment influence whether a person with a genetic risk for alcoholism ever develops the disease. A person's risk for developing alcoholism can increase based on the person's environment, including where and how he or she lives; family, friends, and culture; peer pressure; and even how easy it is to get alcohol.

What Is Alcohol Abuse?
Alcohol abuse differs from alcoholism in that it does not include an extremely strong craving for alcohol, loss of control over drinking, or physical dependence. Alcohol abuse is defined as a pattern of drinking that result in one or more of the following situations within a 12-month period: Failure to fulfill major work, school, or home responsibilities;
Drinking in situations that are physically dangerous, such as while driving a car or operating machinery;

Having recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk; and Continued drinking despite having ongoing relationship problems that are caused or worsened by the drinking.

Although alcohol abuse is basically different from alcoholism, many effects of alcohol abuse are also experienced by alcoholics.

What Are the Signs of a Problem?

Client Screening Questions:
Have you ever felt you should cut down on your drinking?

Have people annoyed you by criticizing your drinking?

Have you ever felt bad or guilty about your drinking?

Have you ever had a drink first thing in the morning (as an "eye opener") to steady your nerves or get rid of a hangover?

One "yes" answer suggests a possible alcohol problem.

If your client answered "yes" to more than one question, it is highly likely that a problem exists.

Even if your client answered "no" to all of the above questions, if they encounter drinking-related problems with their job, relationships, health, or the law, they have alcohol related issues and thus have issues with alcohol.

The effects of alcohol abuse can be extremely serious-even fatal-both to the drinker and to others.

The Decision To Get Help
Accepting the fact that help is needed for an alcohol problem may not be easy. But keep in mind that the sooner someone gets help, the better their chances for a successful recovery.

Any concerns your client may have about discussing drinking-related problems with you may stem from common misconceptions about alcoholism and alcoholic people. In our society, the myth prevails that an alcohol problem is a sign of moral weakness. As a result, they may feel that to seek help is to admit some type of shameful defect in them. In fact, alcoholism is a disease that is no more a sign of weakness than is asthma. Moreover, taking steps to identify a possible drinking problem has an enormous payoff-a chance for a healthier, more rewarding life.

Getting Well
Alcoholism Treatment The type of treatment depends on the severity of the alcoholism and the resources that are available in your community. Treatment may include detoxification (the process of safely getting alcohol out of your system); taking doctor-prescribed medications, such as disulfiram (Antabuse?) or naltrexone (ReViaT), to help prevent a return (or relapse) to drinking once drinking has stopped; and individual and/or group counseling. There are promising types of counseling that teach alcoholics to identify situations and feelings that trigger the urge to drink and to find new ways to cope that do not include alcohol use. These treatments are often provided on an outpatient basis.

Because the support of family members is important to the recovery process, many programs also offer brief marital counseling and family therapy as part of the treatment process. Programs may also link individuals with vital community resources, such as legal assistance, job training, childcare, and parenting classes.

Alcoholics Anonymous
Virtually all alcoholism treatment programs also include Alcoholics Anonymous (AA) meetings. AA describes itself as a "worldwide fellowship of men and women who help each other to stay sober." Although AA is generally recognized as an effective mutual help program for recovering alcoholics, not everyone responds to AA's style or message, and other recovery approaches are available. Even people who are helped by AA usually find that AA works best in combination with other forms of treatment, including counseling and medical care.

Can Alcoholism Be Cured?
Although alcoholism can be treated, a cure is not yet available. In other words, even if an alcoholic has been sober for a long time and has regained health, he or she remains susceptible to relapse and must continue to avoid all alcoholic beverages. "Cutting down" on drinking doesn't work; cutting out alcohol is necessary for a successful recovery. However, even individuals who are determined to stay sober may suffer one or several "slips," or relapses, before achieving long-term sobriety. Relapses are very common and do not mean that a person has failed or cannot recover from alcoholism. Keep in mind, too, that every day that a recovering alcoholic has stayed sober prior to a relapse is extremely valuable time, both to the individual and to his or her family.

If you determine that your client is not alcohol dependent but is involved in a pattern of alcohol abuse, you can help them to:

Examine the benefits of stopping an unhealthy drinking pattern.

Set a drinking goal. Some people choose to abstain from alcohol. Others prefer to limit the amount they drink.

Examine the situations that trigger the unhealthy drinking patterns, and develop new ways of handling those situations so that they can maintain your drinking goal.

Some individuals who have stopped drinking after experiencing alcohol-related problems choose to attend AA meetings for information and support, even though they have not been diagnosed as alcoholic.

Genetics:
Alcoholism is a complex disease. Therefore, there are likely to be many genes involved in increasing a person's risk for alcoholism. Scientists are searching for these genes, and have found areas on chromosomes where they are probably located. Powerful new techniques may permit researchers to identify and measure the specific contribution of each gene to the complex behaviors associated with heavy drinking. This research will provide the basis for new medications to treat alcohol-related problems.

Treatment: Researchers have made considerable progress in evaluating commonly used therapies and in developing new types of therapies to treat alcohol-related problems. One large-scale study found that each of three commonly used behavioral treatments for alcohol abuse and alcoholism-motivation enhancement therapy, cognitive-behavioral therapy, and 12-step facilitation therapy-significantly reduced drinking in the year following treatment. This study also found that approximately one-third of the study participants who were followed up either were still abstinent or were drinking without serious problems 3 years after the study ended. Other therapies that have been evaluated and found effective in reducing alcohol problems include brief intervention for alcohol abusers (individuals who are not dependent on alcohol) and behavioral marital therapy for married alcohol-dependent individuals.

Treatment
Alcohol treatment can be done in many ways. There is the option of inpatient, outpatient, group therapy, and self help. They all offer great benefits and an addict must find what works best for them. The alcohol treatment chosen may include therapy to help the addict understand their behavior and improve their coping mechanisms. A doctor may prescribe medication to relieve the withdrawal symptoms and to help control cravings. The addict may enroll on a self help group to have to support of his or her peers. Alcohol treatment can be provided in many settings including a hospital, a half way house, or outpatient. There are three types of therapy that are widely used in alcohol treatment, motivational enhancement therapy, cognitive-behavioral therapy, and the twelve step program.

Motivational enhancement therapy (MET) seeks to obtain a response from an addict for their own motivation for change and to make it a personal decision and plan for change. The approach is addict centered, although planned and directed. The addict sets his or her own goals; no absolute goal is imposed through MET, although counselors may advise specific goals such as complete abstention. A broader range of life goals may be explored as well. Cognitive-behavioral therapy (CBT) uses a technique that teaches the addict to weaken the behavior caused by trouble situations and teaches them a new way of thinking can improve the situation. The twelve step program is based on guidelines written by alcohol addicts who took control of their lives and chose self-help as their alcohol treatment.

Motivational Enhancement Therapy (MET) seeks to evoke from clients their own motivation for change and to consolidate a personal decision and plan for change. The approach is largely client centered, although planned and directed.

As applied to drug abuse, MET seeks to alter the harmful use of drugs. Because each client sets his or her own goals, no absolute goal is imposed through MET, although counselors may advise specific goals such as complete abstention. A broader range of life goals may be explored as well.

MET is based on principles of cognitive and social psychology. The counselor seeks to develop a discrepancy in the client's perceptions between current behavior and significant personal goals. Consistent with Bem's self-perception theory, emphasis is placed on eliciting from clients self-motivational statements of desire for and commitment to change. The working assumption is that intrinsic motivation is a necessary and often sufficient factor in instigating change. The client is the agent of change, with assistance from the counselor.

Drug problems are viewed as behaviors under at least partial voluntary control of the client, which are subject to normal principles of behavior change. Drugs of abuse are assumed to offer inherent motivating properties to the drug abuser, which by definition have overridden competing motivations. The task in MET is to elicit and strengthen competing motivations.

MET bears many similarities to Rogerian client-centered counseling but is directive rather than nondirective. There are also certain similarities to cognitive therapy and reality therapy.

MET is strikingly dissimilar from counseling approaches designed to oppose denial and break down defenses through direct confrontation. Furthermore, MET differs from behavioral approaches in that no direct advice or skill training is provided.

MET is typically conducted as individual counseling, though family members may also be present and engaged. Group MET is conceivable but untested. MET has been tested and found effective in both outpatient and inpatient settings. There is no necessary or ideal setting.

MET is typically brief, limited to two to four sessions that each last 1 hour. MET can be a suitable prelude to other treatment approaches designed to enhance treatment response. It has been shown to increase client compliance in subsequent alcoholism treatment and thereby to improve outcome.

MET does not formally involve any self-help group, although participation in such groups may be part of a client's chosen change plan. MET is compatible with a 12-step approach.

MET has been effectively administered by pre-bachelor's level university students working as supervised paraprofessional counselors. Education level may not be a critical determinant of effectiveness in using MET.

Specific training in MET is important. A skillful MET
practitioner makes the process look easy and natural, but in fact the component skills require substantial practice and shaping.

Initial intensive training of 2 to 3 days with subsequent supervised experience in MET is recommended. Training initially focuses on the rationale for MET and the establishment of sound reflective listening skills without which other aspects of MET cannot be implemented effectively. Once these skills are in place, training proceeds to other strategies for enhancing motivation and strengthening commitment to change. Counselors new to this approach are unlikely to implement it successfully, based on a single workshop, without ongoing supervision.

The counselor's recovery status is largely irrelevant in MET. Some research has found that counselors in early recovery tend to over identify with clients and have difficulty in separating their own issues and advice from the counseling process. This would be a particular hindrance in MET

MET requires a high level of therapeutic empathy as defined by Carl Rogers (as opposed to empathy in the sense of having had similar experiences). High interpersonal warmth and congruence are also desirable. Counselors who cannot suspend their own needs, perceptions, and advice are ill suited to MET.

Common counselor behaviors in MET include asking open-ended questions, reflective listening, reframing, and supporting. A key strategy is developing discrepancy by eliciting the client's own verbal expression of problems, concerns, reasons for change, and optimism regarding change. Counselors are instructed to "roll with" resistance rather than confronting it directly. Emphasis is also given to supporting client self-efficacy, the perception that change is possible and can be accomplished by the client. Assessment findings are often used as personal feedback to instill client motivation.

Most important is for the counselor to avoid what is termed the confrontation/denial trap, in which the counselor is placed in the position of defending the presence of a problem and the need for change, while the client argues that there is no problem or need for change. Argumentation is generally proscribed. The counselor also avoids taking on an "expert" role, which implies that the counselor will impart the solution to the client. Relatedly, counselors are encouraged to avoid "closed" (short answer) questions and specifically to avoid asking three questions in a row. Diagnostic labeling as problem drinker or alcoholic, for example, is specifically avoided.

Direct observation of sessions is vital to effective supervision with MET. Counselors are least able to observe or convey the very behaviors they most need to change. In advance of or during supervision, supervisors should review videotape or audiotape of sessions. It is particularly helpful for the supervisor and those supervised to use a structured observation sheet in following the sessions, coding the content of counselor and client responses as a means of attending to process rather than being caught up in content. Specific workshops for trainers of motivational interviewing are offered periodically.

The counselor's primary role is to elicit and consolidate the client's intrinsic motivations for change. This facilitator role may include minor aspects as educator and collaborator. The expert/adviser role is deemphasized. When personal assessment feedback is provided as part of MET, the counselor temporarily assumes the role of educator.

The client should do more than half of the talking, except during a period of personal assessment feedback when the counselor has a substantial explanatory role.

MET sessions are client centered but directive. There is a specific objective that the counselor pursues through systematic strategies. When MET is successfully conducted, however, the client does not feel directed, coerced, or advised. Direction is typically accomplished through open-ended questions and selective reflection of client material rather than through more overtly confrontational strategies and advice giving. To use a metaphor, the client and counselor are working a jigsaw puzzle together. Rather than putting the pieces in place while the client watches, the counselor helps to construct the frame, then puts pieces on the table for the client to place.

The rapid establishment of a working therapeutic alliance is an important aspect of MET. The basic conditions of client-centered therapy provide a strong foundation, with particular emphasis on the strategies of open-ended questions and reflective listening. Such supportive and motivation-building strategies are employed until resistance abates and the client shows indication of being ready to discuss change.

Research to date has found MET to be effective with a broad range of severity of alcohol problems. No unique markers of differential response have been identified. Court-mandated clients appear to respond as favorably as those who are self-referred. One study has shown MET to be differentially effective (relative to a behavioral approach) with clients in the earliest stages of change (i.e., most unmotivated). MET has been evaluated well with problem drinkers, but its results are less studied with other drug problems. Two studies have reported positive results with marijuana and heroin users. The basic therapeutic style would remain the same regardless of target drug, but specific content (e.g., assessment feedback) may vary.

MET may be insufficiently directive for clients who desire clear direction and advice. Research to date has identified no client characteristics that predict poorer response to MET than to alternative approaches. Brief counseling in general may be less effective as a stand-alone treatment with more severely impaired clients.

MET commonly includes a structured assessment of use, consequences, addiction, biomedical sequelae, family history, and other risk factors. A variety of specific instruments could be used to assess these dimensions. Instruments that are sensitive to early stages of impairment are particularly desirable. A common sequence is to conduct a brief motivational interview to prepare the client for assessment. This is followed by structured assessment including the above dimensions. A third session then provides the client with personal feedback regarding the findings from assessment in relation to norms.

The content of an MET session depends on the client's stage of motivation. Prochaska and colleagues (1992) have described four stages of readiness:

Precontemplation, in which the individual is not considering change.

Contemplation, in which the individual is ambivalent, weighing the pros and cons of change.

Determination or preparation, where the balance tips in favor of change and the individual begins considering options.

Action, which involves the individual taking specific steps to accomplish change.

With precontemplators, the counselor explores perceived positive and negative aspects of use. Open-ended questions are used to elicit client expression, and reflective paraphrase is used to reinforce key points of motivation. During a session following structured assessment, most of the time is devoted to explaining feedback to the client. Later in MET, attention is devoted to developing and consolidating a change plan.

The theme of the session is typically determined by the counselor, but specific content within the theme is provided by the client. Examples of common themes include:

• Good and not-so-good things about use.
• A typical day involving use.
• Reasons to quit or change.
• Ideas about how change might occur.

Sessions commonly begin with open-ended questions and end with a summary reflection.

Sessions are rather structured, although in presentation they are flexible and client centered.

Resistance of all types is met by a reflective "rolling with" strategy, rather than direct confrontation or opposition. For example, client minimization or rationalization might be met with various forms of reflective listening, such as double-sided reflection, where both sides of ambivalence are captured. The counselor might also agree with the client's point but then reframe it. Standard program rules (e.g., regarding coming to sessions under the influence) may, of course, still be enforced.

The central characteristic of MET is as follows: Resistance and poor motivation are not regarded as client characteristics but rather as cognitions and behaviors subject to interpersonal influence. Research demonstrates that a counselor can drive resistance levels up and down dramatically according to his or her personal counseling style. A respectful, reflective approach is used throughout MET with minimal advice or direction. The goal is still confrontation in the sense of bringing the client face to face with a difficult reality and thereby initiating change. Common strategies for decreasing resistance behaviors include variations on reflective listening (e.g., amplified reflection, in which the counselor takes the client's resistance a step further), reframing or giving a new meaning to what the client has said, and selective agreement. Many of these take the form of the counselor giving voice to the client's resistance, seeking to elicit the client's own verbalizations of the need for change.

Crises often offer particularly good windows of opportunity for motivation. Rapid availability of the MET counselor is desirable. Beyond the taking of immediate actions necessary to ensure safety, counseling strategies remain largely the same.

Occurrences of renewed use are queried through open-ended questions and are explored through reflective listening. Judgmental responses are carefully avoided. The client's own perceptions of the slip or relapse are explored, and renewed attention is given to the change plan and to what if anything may have been faulty in the prior plan.

Significant others (SOs) may be involved in MET sessions and can be useful sources of motivational material and change plans. The counselor must ensure that the SO does not behave in a manner that elicits resistance and inhibits motivation for change. The SO's primary role is to offer his or her own observations and perceptions, with focus remaining on eliciting the client's intrinsic motivation. The counselor may also employ MET strategies to strengthen the SO's own motivation for change and elicit plans for behavior change. SO's involvement can also make reasons for change more salient for the client. The implicit goal remains to instigate change in the client.

Cognitive-Behavioral Therapy (CBT)
is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. Cognitive-behavioral therapist teach that when our brains are healthy, it is our thinking that causes us to feel and act the way we do. Therefore, if we are experiencing unwanted feelings and behaviors, it is important to identify the thinking that is causing the feelings / behaviors and to learn how to replace this thinking with thoughts that lead to more desirable reactions.

There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.

However, most cognitive-behavioral therapies have the following characteristics:

1. CBT is based on the Cognitive Model of Emotional Response.
   Cognitive-behavioral therapy is based on the scientific fact that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.
2. CBT is Briefer and Time-Limited.
   Cognitive-behavioral therapy is considered among the "fastest" in terms of results obtained. The average number of sessions clients receive (across all types of problems) is only 16. Other forms of therapy, like psychoanalysis, can take years. What enables CBT to be briefer is its highly instructional nature and the fact that it makes use of homework assignments.
3. A sound therapeutic relationship is necessary for effective therapy, but not the focus.
   Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. Cognitive-behavioral therapists believe it is important to have a good, trusting relationship, but that is not enough. CBT therapists believe that the clients change when they learn to think differently; therefore, CBT therapists focus on teaching rational self-counseling skills.
4. CBT is a collaborative effort between the therapist and the client.
   Cognitive-behavioral therapists seek to learn what their clients want out of life(their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement that learning.
5. CBT is based on stoic philosophy.
   Cognitive-behavioral therapy does not tell people how they should feel. However, most people seeking therapy do not want to feel they way they do. CBT teaches the benefits of feeling, at worst, calm when confronted with undesirable situations. It also emphasizes the fact that we have our undesirable situations whether we are upset about them or not. If we are upset about our problems, we have two problems -- the problem, and our upset about it. Most sane people want to have the fewest number of problems possible.
6. CBT uses the Socratic Method.
   Cognitive-behavioral therapists want to gain a very good understanding of their clients' concerns. That's why they often ask questions. They also encourage their clients to ask questions of themselves, like, "How do I really know that those people are laughing at me?" "Could they be laughing about something else?"
7. CBT is structured and directive.
   Cognitive-behavioral therapists have a specific agenda for each session. Specific techniques / concepts are taught during each session. CBT focuses on helping the client achieve the goals they have set. CBT is directive in that respect. However, CBT therapists do not tell their clients what to do -- rather, they teach their clients how to do.
8. CBT is based on an educational model.
   CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting. While CBT therapists do not present themselves as "know-it-alls", the assumption is that if clients knew what the therapist had to teach them, clients would not have the emotional / behavioral problems they are experiencing.
   
   Therefore, CBT has nothing to do with "just talking". People can "just talk" with anyone.
   
   The educational emphasis of CBT has an additional benefit -- it leads to long term results. When people understand how and why they are doing well, they can continue doing what they are doing to make themselves well.
9. CBT theory and techniques rely on the Inductive Method.
   A central aspect of Rational thinking is that it is based on fact, not simply our assumptions made. Often, we upset ourselves about things when, in fact, the situation isn't like we think it is. If we knew that, we would not waste our time upsetting ourselves.
   
   Therefore, the inductive method encourages us to look at our thoughts as being hypotheses that can be questioned and tested. If we find that our hypotheses are incorrect (because we have new information), then we can change our thinking to be in line with how the situation really is.
   
   There are over 25 very common mental mistakes that people make that cause them to not have the facts straight.
10. Homework is a central feature of CBT.
    If when you attempted to learn your multiplication tables you spent only one hour per week studying them, you might still be wondering what 5 X 5 equals. You very likely spent a great deal of time at home studying your multiplication tables, maybe with flashcards.
    
    The same is the case with psychotherapy. Goal achievement (if obtained) could take a very long time if all a person were only to think about the techniques and topics taught for one hour per week. That's why CBT therapists assign reading assignments and encourage their clients to practice the techniques learned.

Narcotics Anonymous - 12 step Program
NA's earliest self-titled pamphlet, known among members as "the White Booklet," describes Narcotics Anonymous this way:
"NA is a nonprofit fellowship or society of men and women for whom drugs had become a major problem. We ? meet regularly to help each other stay clean. ... We are not interested in what or how much you used ... but only in what you want to do about your problem and how we can help."

Membership is open to all drug addicts, regardless of the particular drug or combination of drugs used. When adapting AA's First Step, the word "addiction" was substituted for "alcohol," thus removing drug-specific language and reflecting the "disease concept" of addiction.

There are no social, religious, economic, racial, ethnic, national, gender, or class-status membership restrictions. There are no dues or fees for membership; while most members regularly contribute small sums to help cover the expenses of meetings, such contributions are not mandatory.

Narcotics Anonymous provides a recovery process and support network inextricably linked together. One of the keys to NA's success is the therapeutic value of addicts working with other addicts. Members share their successes and challenges in overcoming active addiction and living drug-free productive lives through the application of the principles contained within the Twelve Steps and Twelve Traditions of NA. These principles are the core of the Narcotics Anonymous recovery program. Principles incorporated within the steps include:

• admitting there is a problem;
• seeking help;
• engaging in a thorough self-examination;
• confidential self-disclosure;
• making amends for harm done; and
• helping other drug addicts who want to recover.

Central to the Narcotics Anonymous program is its emphasis on practicing spiritual principles. Narcotics Anonymous itself is non-religious, and each member is encouraged to cultivate an individual understanding-religious or not-of this "spiritual awakening."

Narcotics Anonymous is not affiliated with other organizations, including other twelve step programs, treatment centers, or correctional facilities. As an organization, NA does not employ professional counselors or therapists nor does it provide residential facilities or clinics. Additionally, the fellowship does not provide vocational, legal, financial, psychiatric, or medical services. NA has only one mission: to provide an environment in which addicts can help one another stop using drugs and find a new way to live.

In Narcotics Anonymous, members are encouraged to comply with complete abstinence from all drugs including alcohol. It has been the experience of NA members that complete and continuous abstinence provides the best foundation for recovery and personal growth. NA as a whole has no opinion on outside issues, including prescribed medications. Use of psychiatric medication and other medically indicated drugs prescribed by a physician and taken under medical supervision is not seen as compromising a person's recovery in NA.

Service organization
The primary service provided by Narcotics Anonymous is the NA group meeting. Each group runs itself based on principles common to the entire organization, which are spelled out in NA's literature.

Most groups rent space for their weekly meetings in buildings run by public, religious, or civic organizations. Individual members lead the NA meetings while other members take part by sharing in turn about their experiences in recovering from drug addition. Group members also share the activities associated with running a meeting.

In a country where Narcotics Anonymous is a relatively new phenomenon, the NA group is the only level of organization. In places where a number of Narcotics Anonymous groups have had the chance to develop and stabilize, groups will have elected delegates to form a local service committee. These local committees usually offer a number of services. Included among them are:

• distribution of NA literature;
• telephone information services;
• public information presentations for treatment staff, civic organizations, government agencies, and schools;
• panel presentations to acquaint treatment or correctional facility residents with the NA program; and
• meeting directories for individual information and use in scheduling visits by client groups.
• In some countries, especially the larger countries or those where Narcotics Anonymous is well established, a number of local/area committees have come together to create regional committees. These regional committees handle services within their larger geographical boundaries while the local/area
• committees handle local services.

An international delegate assembly known as the World Service Conference provides guidance on issues affecting the entire organization. Primary among the priorities of NA's world services are activities that support young national movements and the translation of Narcotics Anonymous literature. For additional information, contact the World Service Office headquarters in Los Angeles, California. The mailing address, telephone number, fax number, and website address appear at the end of this pamphlet

Positions on related issues or institutions
In order to maintain its focus, Narcotics Anonymous has established a tradition of non-endorsement and does not take positions on anything outside its own specific sphere of activity. Narcotics Anonymous does not express opinions-either pro or con-on civil, social, medical, legal, or religious issues. Additionally, it does not take stands on addiction-related issues such as criminality, law enforcement, drug legalization or penalties, prostitution, HIV/HCV infection, or syringe programs. Narcotics Anonymous is entirely self-supporting and does not accept financial contributions from non-members. Based on the same principle, groups and service committees are run by NA members, for members.

Narcotics Anonymous neither endorses nor opposes any other organization's philosophy or methodology. Its primary competence is in providing a platform upon which drug addicts can share their recovery and experiences with one another. This is not to say that Narcotics Anonymous believes there are not any other "good" or "worthy" organizations. To remain free of the distraction of controversy, NA focuses all of its energy on its particular area of purpose, leaving other organizations to fulfill their own goals.

Cooperating with NA
Although certain traditions guide its relations with other organizations, Narcotics Anonymous welcomes the cooperation of those in government, the clergy, the helping professions, and private voluntary organizations. NA's non-addict friends have been instrumental in getting Narcotics Anonymous started in many countries and helping NA grow.

NA strives to cooperate with others interested in Narcotics Anonymous by providing contact information, literature, and information about recovery through the NA Fellowship. Additionally, NA members are often available to make panel presentations in treatment centers and correctional facilities, sharing the NA program with addicts otherwise unable to attend community-based meetings.

Membership demographics
To offer some general informal observations about the nature of the membership and the effectiveness of the program the following observations are believed to be reasonably accurate. The socioeconomic strata represented by the NA membership vary from country to country. Members of one particular social or economic class start most national NA movements, but as their outreach activities become more effective, the membership becomes more broadly representative of all socioeconomic backgrounds. All ethnic and religious backgrounds are represented among NA members. Once a national movement reaches a certain level of maturity, its membership generally reflects the diversity or homogeneity of the background culture. Membership in Narcotics Anonymous is voluntary; no attendance records are kept either for NA's own purposes or for others. Because of this, it is sometimes difficult to provide interested parties with comprehensive information about NA membership. There is, however, some objective measures that can be shared based on data obtained from members attending one of our world conventions; the diversity of our membership, especially ethnic background, seems to be representative of the geographic location of the survey. The following demographic information was revealed in a survey returned by almost half of the 13,000 attendees at the 2003 NA World Convention held in San Diego, California:

• Gender: 55% male, 45% female.
• Age: 3% 20 years old and under, 12% 21-30 years old, 31% 31-40 years old, 40% 41-50 years old, 13% over age 51, and 1% did not answer.
• Ethnicity: 70% Caucasian, 11% African-American, 11% Hispanic, and 8% other.
• Employment status: 72% employed full-time, 9% employed part-time, 7% unemployed, 3% retired, 3% homemakers, 5% students, and 1% did not answer.
• Continuous abstinence/recovery: ranged from less than one year up to 40 years, with a mean average of 7.4 years.

Rate of growth
Because no attendance records are kept, it is impossible to estimate what percentages of those who come to Narcotics Anonymous remain active in NA over time. The only sure indicator of the program's success is the rapid growth in the number of registered Narcotics Anonymous meetings in recent decades and the rapid spread of

Narcotics Anonymous outside North America.

• In 1978, there were fewer than 200 registered groups in three countries.
• In 1983, more than a dozen countries had 2,966 meetings.
• In 1993, 60 countries had over 13,000 groups holding over 19,000 meetings.
• In 2002, 108 countries had 20,000 groups holding over 30,000 meetings.
• In 2005, there are over 21,500 registered groups holding over 33,500 weekly meetings in 116 countries.

World Service Office
PO Box 9999
Van Nuys, California 91409
Unites States
Telephone: (818) 773-9999 - Fax: (818) 700-0700

Sometimes It Is the Only Choice Left
Sometimes when the alcoholic's problems reach the crisis level, the only choice left to his family is professional intervention.

What is intervention? Basically it comes down to confronting the alcoholic with how his drinking has affected everyone around him. The alcoholic's family, friends, and employers tell the alcoholic in their own words how his (or her) drinking has been a problem in their lives.

But it is not as simple as that.
Interventions should be carefully planned and developed by professional substance abuse counselors who are experienced in such procedures. The only purpose of an intervention is to get the alcoholic to go into a treatment program.

Most alcohol and drug treatment centers have counselors who are trained to help families prepare for the confrontation, which always takes place in a "controlled" environment, specifically selected to put the alcoholic in a position in which he is most likely to listen.

Many times these interventions take place at the workplace, with the full cooperation of the employer.

Sometimes, the intervention comes as a total surprise to the alcoholic, but recently new techniques have been developed in which the members of the intervention team tell the alcoholic that they are talking with a counselor about his drinking problem several days prior to the actual intervention.

Does it work?
With the new method, the alcoholic realizes that the most important people in his life are meeting about his problem, and when he is finally invited to the discussion, he does not feel as "ambushed" as with the earlier intervention techniques.

If the alcoholic does decide to enter the treatment center, he is more apt to be less angry than with the former procedure of surprising him with the confrontation. He feels less manipulated and usually enters the program with the attitude of trying to get better from the start.

With the old method, many times the alcoholic agreed to the treatment, but started the recovery process with an "attitude."

Some Risks Involved
Professional intervention is not an option for every family and every situation. The decision to choose the intervention path is one that should be made carefully and with the advice of an experienced counselor. There are some potential risks.

As one health care professional put it: "There are a fair number of substance abuse treatment centers who have stopped doing these interventions because when the intervention fails, as it sometimes inevitably does, the family can be further torn apart by all the bad feelings about the intervention. Not a small point for a family already on the edge of destruction from having an actively alcoholic member."

"The intervention may fail if the alcoholic doesn't make some important transitions during and after formal treatment, but the alcoholic identified patient may very well storm out of the intervention session and the family will have to pick up the pieces of a failed intervention on top of the rest of their problems."

There are others who believe no intervention can be successful in the long run, because of their experience that most alcoholics can't be helped until they are ready to reach out for help on their own. Although the confrontation itself may in fact put the alcoholic in the frame of mind to be "ready" to get help, it can also be a point of resentment in the future.

There is no known "cure" for alcoholism. It can be treated, but never "cured." Intervention will work only if the alcoholic becomes committed to never taking another drink.

If the alcoholic's problems have progressed so that he has become a danger to himself or others, or if his alcoholism has reached the point that he is no longer capable of looking out for himself, intervention can be a life-saving choice. But it is not a permanent cure. Only the alcoholic himself can turn a 28-day treatment program into a life-long program of recovery.

Recovery
From the AA perspective, recovery could be viewed as a multileveled, complex, developmental process of change at behavioral, cognitive, psychodynamic, systems, and spiritual levels. Not at all static, this process unfolds within four distinct stages, each with a primary focus: drinking, transition, early recovery, and ongoing recovery" (p. 28)

Always Remember: Three Questions/Controversies

1. Is alcoholism/addiction characterized by a fundamental loss of control?
2. Is alcoholism/addiction a symptom of another problem, or is it the cause?
3. Is drinking a privilege that we should seek to preserve or is it the problem?

Disease concept requires dramatic shifts in thinking
Ask yourself: how do you answer these issues/questions?

1. Alcohol/addiction viewed as a problem, not a solution
2. Acceptance of the idea of loss of control
3. Attribution of loss of control to irreversible disease process
4. Alcoholism is a disease process that can be arrested with abstinence but never cured in a manner that allows a return to drinking successfully

Therapist Bias and Belief:

Be aware of your beliefs in these key areas
Personal beliefs about power and control
Etiology and primacy of alcoholism/addiction
Personal experience w/ alcohol and drugs
Expectations for all clients to fit into same model of TX
Challenge of denial
Acceptance of loss of control
Abstinence
AA
Belief in individualized treatment
Beliefs about dependency


Failure to diagnose alcoholism/substance dependency as a primary disorder maintains faulty thinking for both client and professional Not accepted: 1) loss of control, 2) permanence of loss of control, and 3) losses of control as core of problem

The Developmental Model

• The stages and tasks of recovery for the client and therapist are based on the centrality of the loss of control and the developmental process of change that occurs within AA
• Addiction is characterized by a distorted, faulty belief in the power of self-the power to control one's use of a substance
• The move from addiction to recovery is grounded in challenging and relinquishing the belief in one's power over self
• Recovery does not involve finding the best way to control one's intake of alcohol/drugs
• Recovery involves relinquishing the core belief in power over self and accepting the reality of loss of control over one's drinking/drug use.

Stage One: Drinking

• Developing addiction is characterized by changes in behaviors and thinking
• The individual is guided in behavior, perception, and explanations of reality supported by a belief in control.

Core Beliefs:

1. I am NOT an alcoholic/addict.
2. I can CONTROL my drinking/drug use.
3. Alcohol provides the substitute for something missing in the structure of the self (spiritual vacuum).

Task of the Therapist in the Drinking Stage: Challenging Denial

Stage Two: Transition

• The end of drinking and the beginning of abstinence
• Hitting bottom and the point of despair
• Identity transition to: I am an alcoholic and I cannot control my drinking.
• Surrender
• Transferring dependencies

Task of the Therapist in the Transition Stage: Continuing Challenge and Support

• Continued active emphasis on alcohol
• AA participation, therapist cooperation with AA,
• Promotion of partnership: client, AA, and therapist as educator and coach

Stage Three: Early Recovery

• Primary difference between transition/early recovery is marked reduction in impulses that demand an immediate behavioral response.
• Daily attendance at AA, work w/ sponsors
• Self exploration may be difficult

Task of the Therapist in the Early Recovery Stage: Supporter and Monitor

• Continued maintenance of triadic partnership
• Watchful for resistance, relapse symptoms
• Move to psychodynamic interpretations of behavior

Stage Four: Ongoing Recovery

• Continuance of triadic relationship, self-exploration, regular 12-step work and involvement

Task of Therapist

• Traditional psychotherapy
• Move towards interpretation, less monitoring and coaching
• Working on guilt and shame: the integration of step work and psychotherapy
• ACOA issues: alcoholic and child of alcoholic: dual issues: childhood issues

The Progressive Stages of Recovery

The developmental model of recovery (I will call it the DMR for short) is based upon a series of beliefs:

1. Recovery is a long-term process that is not easy.
2. Recovery requires total abstinence from alcohol and other drugs, plus active efforts toward personal growth.
3. There are underlying principles that govern the recovery process.
4. The better we understand these principles, the easier it will be for us to recover.
5. Understanding alone will not promote recovery; the new understanding must be put into action.
6. The actions that are necessary to produce full recovery can be clearly and accurately described as recovery tasks.
7. It is normal and natural to periodically get stuck on the road to recovery. It is not whether you get stuck that determines success or failure, but it is how you cope with the stuck point that counts.

To learn about recovery, it is helpful to divide the process into stages. We will be learning about six different stages of recovery, which I will refer to as

(1) Transition, (2) stabilization, (3) early recovery, (4) middle recovery, (5) late recovery, and (6) maintenance.

During the first recovery stage, transition, we recognize we have problems with chemicals, but we think we can solve them by learning how to control our use. This stage ends when we recognize we are not capable of control - that we are "powerless" over alcohol or other drugs - and we need to abstain to regain control of our lives. We don't yet know why we are out of control or how to stay sober; we just know we cannot continue the way we have been. In AA this is called "being sick and tired of being sick and tired."

During the second stage, stabilization, we now know we have serious problems with alcohol and drug use and that we need to stop using completely, but we are unable to do so. During this time we recuperate from acute withdrawal (the stage of shakiness and confusion that we experience as our bodies detoxify) and from long-term or post-acute withdrawal (the period of time lasting from six to eighteen months when we feel like we are in a mental fog.) During this stage we learn how to stay away from one drink ( or one dose of drugs) "one day at a time."

The third stage, early recovery, is a time of internal change. During early recovery we learn how to become comfortable abstinent. The physical compulsion to use chemicals is relieved, and we learn more about our addiction and how it has affected us. We also learn to overcome our feelings of shame, guilt, and remorse. We become capable of coping with our problems without chemical use. Early recovery ends when we are ready to begin practicing what we learned by straightening out other areas of our lives.

During middle recovery, the fourth stage, we learn how to repair this past damage and put balance in our lives. We learn that full recovery means "practicing these principles [the sober living skills we learned in early recovery] in all of our affairs" (in the real world of daily living). During middle recovery, we make it a priority to straighten out our relationships with people. We reevaluate our significant relationships - including our relationships with family and friends - and our careers. If we find we are unhappy in any of these areas, we admit it and make plans to do something about it. In AA terms, this means making amends. We acknowledge that we have done damage to other people. We become willing to take responsibility to do whatever possible to repair it. Middle recovery ends when we have a balanced and stable life.

During the fifth stage, late recovery, we focus on overcoming obstacles to healthy living that we may have learned as children, before our addiction even developed. Many chemically dependent people come from dysfunctional families. Because our parents may not have done a very good job at parenting, we may never have learned the skills necessary to be happy. Late recovery ends when we have accomplished three things:

• First, we recognize the problems we have as adults that were caused by growing up in a dysfunctional family.
• Second, we learn how to recover from the unresolved pain that was caused by growing up in a dysfunctional family.
• Finally, we learn how to solve current problems in spite of the obstacles caused by how we were raised.

The sixth and final stage is maintenance. During maintenance, we recognize we have a need for continued growth and development as people. We recognize that we can never safely use alcohol and other drugs, and we must practice a daily recovery program to keep addictive thinking from returning. We live in a way that allows us to enjoy the journey of life.

RECOVERY STAGE	MAJOR THEME
1. Transition	Giving up the need to control alcohol and other drug use.
2. Stabilization	Recuperating from the damage caused by addictive use.
3. Early Recovery	Internal change (change of thinking, feeling, and acting related to alcohol and drug use).
4. Middle Recovery	External change (repairing the lifestyle damage caused by addictive use and developing a balanced lifestyle).
5. Late Recovery	Growing beyond childhood limitations.
6. Maintenance	Balanced living and continued growth and development.

Many chemically dependent people ask, "What are some things I might do that would cause a relapse?" The answer is simple. You don't have to do anything. Stop using alcohol and other drugs, but continue to live your life the way you always have. Your disease will do the rest. It will trigger a series of automatic and habitual reactions to life's problems that will create so much pain and discomfort that a return to chemical use will seem like a positive option.

Recovery means change. To change, we must have goals. To reach our goals, it helps to have an action plan or a step-by-step guide showing us what to do and how to do it.

Recovery is a process of growth that takes time. Going from stabilization to maintenance may require three to fifteen years, depending upon how sick you were when you started to recover, how hard and consistently you worked at your recovery plans, and the type of help you received from others.

No program or book contains a magic formula. They simply describe many things that people who have successfully recovered from chemical dependency have done. By understanding what others have done, it becomes possible to follow the advice often heard at AA meetings: "If you want what we got, do what we did." Please accept our descriptions in the spirit that they are offered. It is my intent to share the courage, strength, and hope of hundreds of recovering alcoholics.

Helping Families and Children Cope With the Substance Use Disorder of Someone Close

Substance use disorders impact not only the millions of Americans who have a problem with alcohol and/or drugs, but also their families, friends, and children. People of all generations have been affected by substance use disorders. As many as 74 percent of Americans said in 2005 that addiction to alcohol has had some impact on them at some point in their lives, whether it was their own personal addiction, that of a friend or family member, or any other experience with addiction.

Furthermore, 41 percent of public reports encouraging a loved one to seek help for an alcohol problem. Yet help is available, and like other chronic mental disorders, substance use disorders are medical conditions that can be treated effectively. People in recovery can and do rejoin their families, their jobs, and their lives in their communities.

Substance use disorders involve the dependence on or abuse of alcohol and/or drugs. Dependence on and abuse of alcohol and illicit drugs, which include the non-medical use of prescription drugs, are defined using the American Psychiatric Association's criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Dependence indicates a more severe substance problem than abuse; individuals are classified with abuse of a certain substance only if they are not dependent on that substance. For more information on the criteria used in defining dependence and abuse, consult the 2004 National Survey on Drug Use and Health, which is available on the Web at www.oas.samhsa.gov/nsduh.htm.

Much has been written about substance abuse, dependence, and addiction; many studies have used different terminology to explain their findings. To foster greater understanding and avoid perpetuating the stigma associated with these conditions, the phrase "substance use disorders" is used as an umbrella term to encompass all of these concepts.

Substance use disorders can severely compromise parents' ability to provide a secure and nurturing home for children. In 2001, more than 6 million children lived with at least one parent who abused or was dependent on alcohol or an illicit drug. Children of parents with substance use disorders are generally considered at high risk for biological, developmental, and behavioral problems, including the risk of developing a substance use disorder of their own.

Studies examining the effects of prenatal exposure to alcohol and drugs on the health and early development of children are uncovering the biological vulnerability of children. Yet comparatively little attention has been given to postnatal environmental factors that may negatively impact children's development. A quarter of children whose mothers have substance use disorders exhibit behavioral problems in school. Children of people who have an alcohol use disorder also exhibit symptoms of depression and anxiety more than children of people who do not.

It is important to be aware of your family's habits, particularly when it comes to safe driving habits. In 2004, 10.2 percent of teens ages 16 or 17 and 20.2 percent of 18- to 20-year-olds said they drove under the influence of alcohol at least once in the past year.

Additionally, a growing number of elderly adults have substance use disorders. The number of substance abuse treatment admissions among people aged 55 and older increased by 32 percent between 1995 and 2002. People aged 65 or older make up only 13 percent of the population, yet account for nearly one-third of all medications prescribed in the United States. Older patients are more likely to be prescribed long-term and multiple prescriptions, which could lead to unintentional misuse. They also require lower doses of medicines because the body's ability to metabolize many prescriptions decreases with age, making them more susceptible to the effects of a drug. Signs of an alcohol- or medication-related problem among the elderly that family members should look for include memory trouble after having a drink or taking medicine, loss of coordination, and changes in sleeping habits.

Support for Families of People With Substance Use Disorders

People who have substance use disorders may become increasingly isolated from their families. Beyond the nuclear family, extended family members may have a range of emotions, including abandonment, anxiety, fear, anger, concern, embarrassment, guilt, and even the desire to ignore or cut ties with the person with a substance use disorder.

But there is hope, and family members can play a critical role in supporting loved ones on their path of recovery-ultimately bringing healing to the entire family. A major study published in the Journal of the American Medical Association in 2000 is one of several studies that demonstrate the success of treatments for substance use disorders. Treatment of both mental and substance use disorders can help prevent the exacerbation of other health problems, including cardiac and pulmonary diseases, according to the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Health Disorders in 2002.

Treating the intricate needs of people who have family members with substance use disorders requires a team of professionals that extends beyond the support found in a traditional treatment and recovery setting. A child or other family member needs to recognize that he or she is not the cause of a relative's substance use. Another important lesson is that even though people can't "cure" their relative's substance use disorder, they can help the family member through recovery by caring for and supporting them.

Learning how to treat substance use disorders just like any other chronic disease can help family members understand how to best support a relative who has a substance use disorder. If a substance use disorder is affecting your family, please refer to the SAMHSA publication What is Substance Abuse Treatment? A Booklet for Families at http://kap.samhsa.gov/. You can also order the publication through SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) on the Web at http://ncadi.samhsa.gov/ or by calling 800-729-6686.

The Importance of the Family's Role in Treatment

Fortunately, family members can help people obtain treatment and work to erode societal stigmas against people in recovery by celebrating their successes. Substance use disorder treatment programs with family-oriented approaches can make a difference. Family therapy helps people with substance use disorders use a family's strengths and resources to develop ways to live without alcohol and/or drugs. Family therapy can also help the family make important relationship and environmental changes affecting the member with a substance use disorder. For example, therapy may help other family members work together more effectively and help their relatives set personal goals. Family therapy can also help families recognize their own needs and provide healing for each other, and help prevent substance use disorders from moving from one generation to another.

The Impact of Stigma and Discrimination Within Families

While substance use disorders are medical conditions, and treatment is highly effective, stigma and discrimination can plague people who are in recovery, even within families. Stigma and discrimination present a barrier for people with substance use disorders who wish to access treatment. They also inhibit the ongoing recovery process. Stigma detracts from the character or reputation of a person. For many people, stigma can be a mark of disgrace. In 2004, 21.6 percent of the 1.2 million people who felt they needed treatment but did not receive it indicated it was because of reasons related to stigma.

Stigma can keep family members from disclosing a relative's substance use disorder, which is counterproductive when they are trying to encourage the person to seek treatment. Results from a recent study suggest that families of people with a drug use disorder are viewed by society in the most stigmatizing manner, when compared to families of people with mental illness or emphysema. Society views them as more responsible for the onset of the disorder, and they may feel more ashamed of their family member.

Discrimination, on the other hand, is an act of prejudice. It can include denying someone employment, housing, accommodation, or other services based on the revelation that the person is receiving treatment or has previously been treated for a substance use disorder. Discrimination ignores the fact that substance use disorders can strike people of any age, gender, race, ethnicity, education level, and geographic area.

Families report being blamed by other community members for a relative's disorder and accused of being responsible for any relapses the affected person may experience. Furthermore, family members are more directly affected by the disorder themselves and more likely to be socially avoided.

In particular, stigma and discrimination can affect parents whose children have a substance use disorder or are in recovery. Many families are more comfortable revealing that their child has depression or attention deficit disorder than disclosing that their child is using illegal substances, and are more willing to discuss the problem in a group setting to get help. Conversely, many family support specialists report that when the mental health diagnosis is more severe-for example, a bipolar disorder-families find it more socially acceptable to talk about their child's substance use than to divulge that their child needs an antipsychotic medication. Yet a survey by the Parent/Professional Advocacy League suggests there is a need for integrating treatment of both mental health and substance use disorders together when they co-occur in adolescents.

Families may fear potential consequences if they disclose a relative's illegal drug use, such as legal ramifications. However, a delay in receiving treatment can actually lead to more encounters with the police and court system. Once people with untreated substance use disorders find themselves in the criminal justice system, the system can give them access to treatment programs. In fact, there is an ongoing trend toward addressing drug use disorders with treatment, rather than with punishment. With this in mind, it is important to overcome stigma and help get affected family members an assessment by a health care professional as soon as any problem is recognized.

Talking about a family member's substance use disorder will, in fact, help combat societal stigma because when open discussion occurs, people will realize they aren't alone. Creating an open dialogue about overcoming stigma toward people with substance use disorders and their families can help build a stronger, healthier community.

Therapist tools for working with clients

1. Write your reasons for cutting down or stopping.
Why do you want to drink less? There are many reasons why you may want to cut down or stop drinking. You may want to improve your health, sleep better, or get along better with your family or friends. Make a list of the reasons you want to drink less.

2. Set a drinking goal.
Choose a limit for how much you will drink. You may choose to cut down or not to drink at all. If you are cutting down, keep below these limits:

• Women: No more than one drink a day
• Men: No more than two drinks a day
  
  

  A drink is: a 12-ounce bottle of beer; a 5-ounce glass of wine; or a 1 1/2-ounce shot of liquor.

  
  
  These limits may be too high for some people who have certain medical problems or who are older. Talk with your doctor about the limit that is right for you.
  
  Now-write your drinking goal on a piece of paper. Put it where you can see it, such as on your refrigerator or bathroom mirror. Your paper might look like this:
  
  My drinking goal
  • I will start on this day ____________.
  • I will not drink more than ______ drinks in 1 day.
  • I will not drink more than ______ drinks in 1 week. or
  • I will stop drinking alcohol.
  
  3. Keep a "diary" of your drinking.
  To help you reach your goal, keep a "diary" of your drinking. For example, write down every time you have a drink for 1 week. Try to keep your diary for 3 or 4 weeks. This will show you how much you drink and when. You may be surprised. How different is your goal from the amount you drink now? Use the "drinking diary" below to write down when you drink.
  
  

  Week:
  Day of Week	# of drinks	type of drinks	place consumed
  Monday
  Tuesday
  Wednesday
  Thursday
  Friday
  Saturday
  Sunday

  
  
  Tips for clients
  
  Watch it at home.
  
  Keep a small amount or no alcohol at home. Don't keep temptations around.
  
  Drink slowly.
  
  When you drink, sip your drink slowly. Take a break of 1 hour between drinks. Drink soda, water, or juice after a drink with alcohol. Do not drink on an empty stomach! Eat food when you are drinking.
  
  Take a break from alcohol.
  
  Pick a day or two each week when you will not drink at all. Then, try to stop drinking for 1 week. Think about how you feel physically and emotionally on these days. When you succeed and feel better, you may find it easier to cut down for good.
  
  

  Learn how to say NO. You do not have to drink when other people drink. You do not have to take a drink that is given to you. Practice ways to say no politely. For example, you can tell people you feel better when you drink less. Stay away from people who give you a hard time about not drinking.

  
  
  

  Stay active. What would you like to do instead of drinking? Use the time and money spent on drinking to do something fun with your family or friends. Go out to eat, see a movie, or play sports or a game.

  
  
  Get support.
  Cutting down on your drinking may be difficult at times. Ask your family and friends for support to help you reach your goal. Talk to your doctor if you are having trouble cutting down. Get the help you need to reach your goal.
  
  Watch out for temptations.
  
  Watch out for people, places, or times that make you drink, even if you do not want to. Stay away from people who drink a lot or bars where you used to go. Plan ahead of time what you will do to avoid drinking when you are tempted.
  
  Do not drink when you are angry or upset or have a bad day. These are habits you need to break if you want to drink less.
  
  

  DO NOT GIVE UP! Most people do not cut down or give up drinking all at once. Just like a diet, it is not easy to change. That is okay. If you do not reach your goal the first time, try again. Remember, get support from people who care about you and want to help. Do not give up!

  
  
  http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf

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