4 th – 5 th step workshop greg gable, psyd scott teitelbaum, m.d., fasam ken thompson, m.d., fasam
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4th – 5th Step Workshop
Greg Gable, PsyDScott Teitelbaum, M.D., FASAMKen Thompson, M.D. , FASAM
INTRODUCTIONKen Thompson
Introduction
• Relapse is associated with personality disorders in physicians• Depth and power of 12 steps often underestimated by
professionals• 4th step gives clues to characterologic traits which are
formative of personality styling• Relapse is associated with not doing a thorough 4th step by
self report• 4th step is useful to process resentments, a known relapse
trigger• Useful clinical information is gleaned from group 4th- 5th step
work
RELEVANT RESEARCH & PSYCHOLOGICAL OBSERVATIONS
Greg Gable
Relevant Research
Risk factors for relapse included: Family history of substance use disorder Opiate use in the context of a comorbid psychiatric
disorder Comorbid psychiatric disorder (Largely on Axis I)
Domino, Karen B. MD, MPH; Hornbein, Thomas F. MD; Polissar, Nayak L. PhD; Renner, Ginger; Johnson, Jilda; Alberti, Scott; Hankes, Lynn MD, 2005
Relevant Research
• Cohort of 292 subjects•107 with comorbid diagnosis
– 100 with comorbid Axis I diagnosis– 5 with comorbid Axis II diagnosis– 2 with both
Domino, Karen B. MD, MPH; Hornbein, Thomas F. MD; Polissar, Nayak L. PhD; Renner, Ginger; Johnson, Jilda; Alberti, Scott; Hankes, Lynn MD, 2005
Relevant Research
• 60.3% of assessed physicians suffered from comorbid SUD and psychiatric disorders
• 56.8% with Axis II disorder• 54.5% with Axis I mood disorders• 34.1% combined• 18.2% anxiety disorders
Angres, McGovern, Rawal, Purva, & Shaw, 2002
Relevant Research
•Physicians with comorbid diagnoses:• Did as well in treatment as controls• Seemed to have equivalent treatment outcomes at
follow up• Seemed to report greater degrees of emotional
distress even when engaged in a stable recovery
Angres, McGovern, Rawal, Purva, & Shaw, 2002
Gable 2002
Relevant Research
• 308 physician cohort• 78 physicians with relapse (25%)• 230 physicians with no relapse (75%)
• 78 physician relapse population• 55 physicians reengaged in monitored recovery• 92% of original cohort in monitored recovery of at least
5 years
Gable 2002
Relevant Research
Time to First RelapseYear of relapse f % _____ <1 11 22% 1-5 25 48% 5-10 10 20% >10 4 8%_____
Gable 2002
Drug of ChoiceRelapse Non-relapse
Opioid 23 46% 22 44%
Non-opioid 27 54% 28 56%
Gable 2002
Relapse Relevance
Condition relapse non-relapse
Abuse * 26 52% 22 45%Family SUD 30 61% 37 75%Eating Disorder 10 20% 11 21%
Compulsive Behaviors 15 30% 11 21%_________________
* Emotional/Physical/Sexual Abuse
Gable 2002
Relapse Relevance
• The presence of an Axis II disorder was strongly related to relapse
– (χ² = 16.071, df = 1, p<.05) (46% of the relapse group had an Axis II diagnosis, compared to eight percent of the non-relapse group). (p actually computed as .000)
Gable 2002
Relapse RelevancePersonality Disorder Diagnosis
Diagnosis relapse non-relapseOCPD 4 8% 0 0% NPD 2 4% 0 0%
BPD 2 4% 0 0%
PD NOS 15 30% 4 8%
Gable 2002
Relapse Relevance
• The presence of a comorbid Axis I diagnosis was significantly related to relapse – ( χ² = 9.180, df = 1, p<.05). (p computed to .002)
Gable 2002
Relapse relevance
Axis I disorder relapse non-relapse
Bipolar 6 12% 1 2%MDD 12 24% 7 14%Dysthymic 1 2% 2 4%Bulimia 3 6% 3 6%PTSD 1 2% 1 2%Anxiety/Panic 3 6% 0 0%OCD 1 2% 0 0%Sexual 1 2% 0 0%ADHD 1 2% 0 0%(43% of overall sample had a comorbid Axis I dx)
Gable 2002
Relapse Relapse
• When the presence of an Axis II disorder is combined with the presence of an secondary Axis I disorder (not including secondary substance use disorder diagnoses), the presence of a co-occurring psychiatric disorder on Axis I or Axis II was strongly related to relapse (χ² = 23.645, df=1, p<.05). (p actually computed to .000)
Gable 2002
Relapse Relevance
Relapse Status f % of group
Relapse 41 82%No Relapse 17 34%
Note: Comorbid secondary substance use disorders are not included
Project Match Data
• Compared CBT, MET, and TSF• Months 4 to 15 Sobriety
– CBT = 15%– MET = 14%– TSF = 24%
• The advantage of TSF endured through the 12 month follow up period (NIAAA)
Personality/Relational Issues as Relapse Factor
Presence of relational difficulties presents barriers to effective long-term use of tools
Traits increase relapse risk because: Less assiduous use of tools Pt. can revert to pre-recovery coping mechanisms at
times of heightened emotional stimulation (positive or negative)
Learned use of tools over time can decay
Diagnostic Issues
• Danger in diagnosing personality disorder too early in treatment process
• Danger in diverting patient focus from addiction to “psychological issues”
• Tendency to postpone addressing of these issues in favor of recovery tools/comparing in.
Implications for Treatment/Recovery
• Trauma often a factor• Important to help patient identify the trauma
and importance for working with it over time• Important not to avoid trauma material in
treatment• Unresolved/undisclosed trauma can prevent
honest sharing with others
Case Study Sarah
• Internist• Treated in long-term residential• Relapsed soon after to meds not covered on HP
panel (after researching this)• Flew under radar for over a year, then relapse
became visible• Returned to long-term residential treatment• Personality issues, cluster B a problem in
treatment
Case Study Sarah
• Discharged early because of rule violations• Struggled in outpatient, willful, not accepting
of treatment plan• About 8 months after second tx experience,
began to show changes• When interviewed, identified sponsor and 4th
step as change agent
Case Study Sarah
• Mary identified a character defect as having been central to her difficulty in recovery
• When asked to name this defect, she did not describe narcissistic, borderline or antisocial traits.
• She talked about becoming aware of her intolerance, lack of acceptance
• This construct was, for her, something to build change upon.
Project Match Data
-Compared CBT, MET, and TSF-Months 4 to 15 Sobriety
CBT = 15%MET = 14%TSF = 24%
The advantage of TSF endured through the 12 month follow up period (NIAAA)
What we have learned
• Important to bring the traits into awareness • Important to make work on the traits part of the
treatment/recovery plan• Important for clinicians to communicate to other
providers about presence and potential effects of traits
• Not important to have pt. arrive at acceptance of a specific diagnosis
What have we learned?
• Identifying trauma and characterologic issues early as possible is important
• 4th step and enneagram are helpful in bringing relapse issues into the light
• It is not so important to diagnose except to communicate with other treaters
• People are willing to get rid of things that they deem as non-functional.
• On going attention to this by “monitoring” groups might be important – group 4th step work and or enneagrams might be useful
DEPTH & POWER OF STEPS 4, 5, 6 & 7Scott Teitelbaum
Depth of the Steps
• Underestimated by many professionals• More than just meetings• Ability to assess personality styling• Open the door to transformation of
personality
Spiritual Principles – Psychiatric Counterparts
• Step 1 – honesty• Step 2 – hope• Step 3 – faith• Step 4 – courage• Step 5 – integrity• Step 6 – willingness• Step 7 – humility• Step 8 – brotherly love• Step 9 – justice• Step 10 – perseverance• Step 11 – spirituality• Step 12 – service
Resentments
• “For when harboring such feelings we shut ourselves off from the sunlight of the Spirit. The insanity of alcohol returns and we drink again. And with us, to drink is to die”.
• Common cause of relapse• Reflects a deep spiritual problem• Fear and hurt underlie the anger
4th Step
• Personal Inventory• Explores - resentments, fears, wounds, secrets• Looks for character defects to remove• Can be used as a diagnostic tool?
4TH STEP BY THE COLUMNSKen Thompson
4th Step – 4 columnsI’m resentful at The cause Affects my Character defects
I’m resentful at The cause Affects my Character defects
Father
Bob - peer
I’m resentful at The cause Affects my Character defects
Father UnemotionalHigh expectationsNever attended any of my sports activitiesPhysically abusive
Bob Attention to my wifeDid not pay money he owedTook my job
“ The Ouch”
“Spiritual Wound”
I’m resentful at The cause Affects my Character defects
Father UnemotionalHigh expectationsNever attended any of my sports activitiesAlways at workPhysically abusive
Self esteemSense of comfortSecurity
Bob Attention to my wifeDid not pay money he owedTook my job
Sex relationsFinancial security
“Spiritual Wound”
I’m resentful at The cause Affects my Character defects
Father UnemotionalHigh expectationsNever attended any of my sports activitiesAlways at workPhysically abusive
Self esteemSense of comfortSecurity
Emotionally distantPerfectionisticEntitled
Bob Attention to my wifeDid not pay money he owedTook my job
Sex relationsFinancial security
Wrath, vengefulLust
Personality Styling
Self centered fear
Move on to steps 5, 6, & 7
“ The Ouch”
Common Doctor Defects
• Perfectionism• Care taking• People pleasing• Intellectualism• Arrogance-entitlement• Workaholism
OBSERVATIONSKen Thompson & Scott Teitelbaum
I’m resentful at The cause Affects my Character defects
Father UnemotionalHigh expectationsNever attended any of my sports activitiesAlways at workPhysically abusive
Self esteemSense of comfortSecurity
Emotional distantIsolativeArrogantEntitled
Bob Attention to my wifeDid not pay money he owedTook my job
Sex relationsFinancial security
Wrath, vengefulLustGreed
May not see the resentment or too ashamed to address it
May continue to justify the behaviors Do not see connection to “wound”Do not see them as still active in life
May not feel the ouchNot able to see impact on securityNot able to see the fear
May negate the resentment since they realize they did something wrong as wellNot emotionally connected
The Barriers to a 4th step
CASE STUDIES
BARRIERSAll of us
Barriers
• Religious perceptions• Morality as issue • Lack of understanding of 12 steps
WHAT WE HAVE LEARNEDGreg Gable, Scott Teitelbaum, Ken Thompson
Diagnostic Issues
• Danger in diagnosing personality disorder too early in treatment process
• Danger in diverting patient focus from addiction to “psychological issues”
What we have learnedCharacter Defects
• Require energy to maintain• Driven by “wound”• Create distress• Distress may look like anxiety, depression• Attempts to medicate is common (by client
but also by “psychiatrists”)
What we have learned
• Important to bring the traits/defects into awareness
• Important to make work on the traits part of the treatment/recovery plan
• Important for clinicians to communicate to other providers about presence and potential effects of traits/defects
• Not important to have pt. arrive at acceptance of a specific diagnosis
What have we learned?
• Identifying trauma and characterologic issues early as possible is important
• 4th step is helpful in bringing relapse issues into the light
• People are willing to get rid of things that they deem as rotten.
• On going attention to this by “monitoring” groups might be important – group 4th 5th step work
THE FUTURE
The Future
• Operationalizing group – captive audience in monitored physician groups
• Encouragement of working steps – possible reduction in relapse
• Ability to see changes in recovery trajectory
Operationalizing
• Method of the group• Findings by consensus• Measurable components of the 4th- 5th step
group
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