Peer Manual For Peer Led Ambulatory Care For Drug Abuse

TRAINING MANUAL FOR PEER - LED AMBULATORY CLINIC TREATMENT FOR DRUG ABUSE

PI: Marc Galanter, M.D. This manual is based on the Recovery Treatment Program developed by the Division of Alcoholism and Drug Abuse of New York University Medical Center at Bellevue Hospital Center under contract grant from the New York State Addiction Technology Transfer Center (ATTC). The New York State ATTC is a federal initiative funded through the Department of Mental Health and Human Services’ Center for Substance Abuse Treatment (CSAT), directed by the New York State Office of Alcohol and Substance Abuse Services, and managed by the Nelson A. Rockefeller College of Public Affairs and Policy Professional Development Program, 1998. The source material was compiled by Aimee Trotter under the supervision of the Recovery Clinic Director, Carlotta Schuster and staff. This material was further developed into a training manual for staff by Drs. Helen Dermatis and Susan Egelko.

TABLE OF CONTENTS Manual Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Treatment Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Sample Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Objective I

Understand Program Phases and Stages of Recovery . . . . . . . . . . . . . . 7-17

Objective II Understand and Promote Self-Help and Mutual Help . . . . . . . . . . . . . . 18-27 Objective III Understand and Practice Positive Role Modeling . . . . . . . . . . . . . . . . . 28-30 Objective IV Understand and Promote the Concept of “No We-They Dichotomy” . 31-32 Objective V Understand and Promote Upward Mobility and the Privilege System 33-38 Objective VI Understand and Promote Adherence to Program Rules . . . . . . . . . . . . 39-53 Pre-Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40-41 Post-Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51-52 Objective VII Facilitate Communication with Dually Disordered to Minimize Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54-55 Focus Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Appendices I.A. Stages of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58-60 I.B. Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61-62 I.C. Orientation Phase Contract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 II.A. Pre- and Post-Test Answer Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 II.B. Recovery Clinic Philosophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Manual Overview Recovery Clinic is a modified TC located at Bellevue Hospital Center in New York City, targeted to inner city substance abusers. The training manual for staff that follows is based on eight years of its operation. During this time period, cocaine has been the primary drug of abuse although this manual is applicable to other drugs of abuse. Members have been primarily drawn from two disenfranchised patient groups: (1) those with comorbid major psychiatric illness and (2) pregnant women and women with infants. The 9-month treatment program blends a peer leadership model with professional supervision. Members attend the program five days per week, with a full complement of treatment groups which focus on abstinence issues, management of psychiatric symptoms, life skills, and prevocational readiness. The model of treatment is one of empowerment of the community of peers. An empowerment model requires staff to play a role of facilitation, rather than direction, of clinical activities. In a TC setting, members are expected to behave in a responsible fashion, abiding by the rules of the community (e.g., re: attendance, punctuality, dress code, use of profanity, etc.). These behavioral requirements are no different than for staff who themselves must function as role models and behave in accordance with the rules of the treatment community. A full understanding of these guidelines is essential to knowing the precise expectations of all members, both newcomers and more senior members. It is the responsibility of staff to monitor the functioning of the community at all times and assist members in clarifying rules and determining appropriate sanctions when guidelines are violated. The manual begins with a discussion of the treatment approach and then focuses on the primary objectives. For each objective, trainer note, content and relevant exercises are presented. We will use the term “trainee” to signify the professional audience that will be taking the course and “peer” to signify the patient population for whom this treatment approach has been developed.

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Treatment Approach The principal treatment modality in the Recovery Clinic program is peer-based selfhelp. It is used to promote a sense of mutuality among the patients and a goal of abstinence. From the outset of their exposure to the program, peers are led to understand that conduct of the therapy is primarily in the hands of the group under the leadership of its abstinent senior patients. Professionals, however, carry out evaluation and counseling, prescribe psychiatric medication (psychiatrist only), and assume some leadership functions. Peers spend most of the time in conjoint activities in a large day room. Roles assigned to them include contacting new patients in the inpatient service of our facility and orienting them to the program, confronting peers' maladaptive defenses and drug use, and promoting an orientation toward drug-free community adaptation. Most therapeutic groups are managed by peers who have been in the program for at least several months. In these groups, communication is frank but supportive. Although disruptive behavior and evidence of drug use is openly confronted, the tone, as modeled by the professional staff, includes a respect for the psychological limitations of patients and an acknowledgment that some have serious psychiatric disorders.

Target Audience This training manual is primarily targeted to addiction counselors and masters level counselors with limited experience in addiction. It provides essential information about peer-led clinic treatment for drug abuse. The manual may also be useful to doctoral level professionals in addiction care who want more specific training in the TC model. It is recommended that the maximum number of participants in this training be set at 12.

Context For Manual Development Input was solicited from each and every treatment provider associated with the program as well as senior peers (i.e., participating patient group leaders) with particular emphasis placed on developing operational definitions for acceptable behavior in treatment. This manual is focused on common knowledge and expectations of the treatment providers and senior peers rather than specialized expertise of any one type of treatment provider. Input from the following disciplines was represented in the final version of this manual: social work, psychology, psychiatry, addiction counseling, and nursing. The input of senior peers was particularly helpful in ensuring that training materials were clear, free of professional jargon, and respectful of patient concerns. We have identified 7 primary competency areas, incorporating training goals in this curriculum consistent with the Board of Directors of the Therapeutic Communities of America (Kerr, 1986 in De Leon & Ziegenfuss, 1986).

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Objectives I. Understand program phases and stages of recovery. II. Understand and promote self-help and mutual help. III. Understand and practice positive role modeling. IV. Understand and promote the concept of "no we-they dichotomy". V. Understand and promote upward mobility and the privilege system. VI. Understand and promote adherence to program rules. VII. Facilitate communication with dually disordered to minimize resistance.

We have arranged these objectives so that the general underpinnings of the program are conveyed first followed by the specific therapeutic features of the program.

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Sample Agenda Day 1 20 minutes

Registration and Introduction

180 minutes recovery

Objective I Understand program phases and stages of

100 minutes

Objective II Understand and promote self-help and mutual help

60 minutes

Objective III Understand and practice positive role modeling

Day 2 90 minutes Objective IV Understand and promote the concept of “no we-they dichotomy” 120 minutes Objective V Understand and promote upward mobility and the privilege system 120 minutes

Objective VI Understand and promote adherence to program rules

90 minutes Objective VII Facilitate communication with dually disordered to minimize resistance Note: A 60 minute lunch and two 10-15 minute breaks should be incorporated into each day’s agenda.

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Objective I Understand program phases and stages of recovery Estimated time for delivery: 3 hours Trainer Note It is essential that professional staff are not only knowledgeable in all aspects of the treatment program but can also teach effective communication of this information to peers. The peers themselves will be expected to orient newcomers to the program and manage therapeutic groups. Content The traditional TC contains a "treatment protocol organized into phases that reflects a developmental view of the change process" with the "emphasis on incremental learning at each phase, which moves the individual to the next stage of recovery" (De Leon, 1997 pg. 8). The Recovery Clinic program consists of an orientation phase (one month), engagement phase (three months), pre-vocational phase (two months), re-entry phase (three months), and the final phase - aftercare (four to six months). Each phase is associated with its own unique set of behaviors to be learned. The trainer outlines the program description, phases of treatment, and behaviors to be learned during each phase (see handout #I.1 Overview of Program and Phases of Treatment) in a one hour lecture format. The program phases were developed in accordance with stages of recovery. Stages of recovery are reviewed during this segment (see appendix I.A Stages of Recovery) as well as common terminology used in the Recovery Clinic program compatible with a TC model of care (see appendix I.B). The special vocabulary used in the Recovery Clinic program reflects not only individual integration into the peer community but also clinical progress. According to DeLeon (1997), the gradual shift in attitudes, behaviors, and values consistent with recovery is reflected in how well members master the terms of the glossary. Use of the TC terminology constitutes an explicit measure of peers' affiliation and socialization in the TC community. Exercise Have group test their recall concerning phases of treatment and behaviors to be learned by breaking into dyads and role play description of the program phases to each other using TC terminology. Trainees should alternate playing the role of peer versus role of professional staff member and make use of orientation phase contract form (see Appendix I.C).

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Objective I Understand program phases and stages of recovery (cont.) Handout I.1 OVERVIEW OF PROGRAM AND PHASES OF TREATMENT WHAT IS RECOVERY CLINIC? HOW DOES IT WORK? Recovery Clinic is a drug-free, peer-led treatment program for individuals addicted to cocaine and other drugs. The program helps these individuals achieve stable abstinence and develop positive behaviors and attitudes necessary for drug-free living. The program consists of structured groups, job functions, and social activities. The program meets Monday through Friday from 9:00 a.m. until 2:00 p.m. Treatment at Recovery Clinic is different from treatment at other clinics. At Recovery Clinic the main treatment does not come from a doctor, nurse or therapist. Instead, treatment comes from the member community. It is the community which teaches "right" thinking and behavior, and identifies destructive thinking and behavior. The community supports and encourages its members. This is what makes Recovery Clinic a "self-help" program. WHO IS ELIGIBLE FOR ADMISSION? •

Addicted individuals

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Mentally ill individuals addicted to crack/cocaine as well as other substances.

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Women addicted to crack/cocaine as well as other substances, who are pregnant or have infants up to the age of three. Recovery Clinic provides parenting education and infant assessment.

WHAT IS THE PERINATAL PROGRAM? The Perinatal Program is part of the day treatment Recovery Program at Bellevue Hospital and provides comprehensive services for pregnant women and women with infants. When appropriate the women's family and child placement workers are included in the treatment plan. These women participate in the overall recovery community's groups to gain insight into behaviors associated with addiction and to build a peer support system for recovery. HOW LONG IS THE RECOVERY PROGRAM? The day treatment program (Monday through Friday) is nine months, followed by a four to six month Aftercare Phase (with one weekly group).

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Objective I Understand program phases and stages of recovery (cont.) Handout I.1 continued Phases of Treatment I. ORIENTATION PHASE (one month) For newcomers to Recovery Clinic, the first phase of treatment is Orientation. The purpose of Orientation is to determine whether the program is appropriate to the individual's treatment needs, or whether the individual should be referred to a different program. During Orientation the peer is expected to fully participate in the program and follow all the rules and regulations. Peer orientation consists of the peer doing the following: ~ Signing an Orientation Contract and complying with its conditions. ~ Attending a weekly orientation group which is co-led by a senior peer. In this group, peers will get information about how the program works and what is expected. Peers also receive support and advice about how to benefit most from Recovery Clinic. ~ Submitting daily urines for the first two weeks. ~ Starting to identify personal issues (including denial) that impact on recovery. ~ Focusing on becoming a part of the recovery community. ~ Meeting with staff to complete medical, psychological and social assessments. ~ Completing process for obtaining public assistance and Medicaid if necessary. For Perinatal mothers: ~ Introduction to Parenting Skills. ~ Stabilizing relationship with birth father. IMPORTANT BEHAVIORS TO BE LEARNED DURING ORIENTATION PHASE •

PUNCTUALITY AND ATTENDANCE: Peers should be at the program by 9:00 am Monday through Friday (half hour before group) in order to register at the front desk, submit urine samples, check in with their counselors and see the nurse to address any medical issues.

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Objective I Understand program phases and stages of recovery (cont.) Handout I.1. continued IMPORTANT BEHAVIORS TO BE LEARNED DURING ORIENTATION PHASE (cont.) •

SELF-DISCLOSURE refers to peers' truthfully telling their story. Honesty is emphasized as the cornerstone of recovery.

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LISTENING: Keeping an open mind.

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SUBMITTING URINES ON TIME DAILY: No later than 9:30. If peers have excused

lateness they may turn urines in between 12:15 and 12:30. •

RESPECT FOR AUTHORITY: Peers are expected to follow directions of community leadership and staff.

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FRUSTRATION TOLERANCE: Start to talk out their feelings without acting them out.

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COMPLETE THEIR JOB TASKS: Every peer starts out on service crew. This is their opportunity to begin showing their commitment to the community and their recovery.

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ATTEND OUTSIDE 12-STEP MEETINGS: They are encouraged to ask for help and follow suggestions.

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LEARNING THE RULES OF THE PROGRAM.

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RECOGNIZE THE FIRST STEP: "We admitted we were powerless over our addiction and our lives had become unmanageable."

For Perinatal mothers: • ATTEND ALL MEDICAL APPOINTMENTS FOR THEMSELVES AND THEIR INFANTS. • LEARN ACTIVITIES TO INCREASE BONDING WITH NEWBORNS. II. ENGAGEMENT PHASE (three months) During Orientation peers have learned about how the program works and what is expected of them. In addition to what they have learned in Orientation, for the next three months they will focus on the following: ~

Achieving sobriety, one day at a time.

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Objective I Understand program phases and stages of recovery (cont.) Handout I.1 continued ~

Identifying triggers to relapse ("people, places and things"). This will be accomplished by learning to be honest and open about their feelings and behaviors.

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Learning ways to protect their sobriety (relapse prevention.)

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Learning from any mistakes: If they relapse, learning how to deal with them honestly by talking to their peers and discussing it in groups.

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Understanding and using 12-step principles.

For Perinatal mothers: ~ Learning and utilizing parenting skills. ~ Improving relations with birth father. ~ Involving family in child care. ~ Learning to negotiate systems on behalf of self and baby. IMPORTANT BEHAVIORS TO BE LEARNED DURING ENGAGEMENT PHASE: (Addressing negative behaviors) •

LEARNING TO "WALK THE WALK NOT JUST TALK THE TALK."

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GETTING A HOME GROUP AND A SPONSOR.

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EARN A PROMOTION ON COMMUNITY JOB LADDER BY PERFORMING JOB FUNCTIONS RESPONSIBLY.

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LEARN TO HOLD ONE'S BELLY.

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TAKE RESPONSIBILITY FOR ONESELF: Admit when one is wrong. Take credit when one is right.

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SHOW RESPONSIBLE CONCERN: Give pull-ups, push-ups, drop slips, avoid negative contracts, no hiding drug behaviors of others.

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BE SELF-MOTIVATED: Do the task one is assigned without needing to be reminded.

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TAKE PRIDE IN ONE’S WORK: Do the best job possible. 11

Objective I Understand program phases and stages of recovery (cont.) Handout I.1 continued •

LET GO OF ONE'S STREET IMAGE: Stop swearing, no visible beepers, no sunglasses worn inside, no listening to walkmans.

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PARTICIPATE IN HEALTHY DRUG-FREE ACTIVITIES: Both in the program and in outside community.

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BEGIN TO PARTICIPATE IN TAKING CARE OF ONE'S HEALTH CARE NEEDS: Report health care needs to staff and keep medical and dental appointments.

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BEGIN KEEPING TRACK OF ALL ONE'S OWN MEDICAL AND SOCIAL SERVICE APPOINTMENTS

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MAINTAIN STABLE HOUSING: Don't lose housing. Follow the rules of one's residence or shelter.

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DO NOT BORROW FROM OR LEND MONEY TO PEERS.

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LEARN TO MANAGE ONE'S MONEY: So one can pay one's dues and be sure to have carfare to get to all outside appointments.

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CONTACT A MINIMUM OF 2 PEERS DURING THE WEEK AND TWO PEERS OVER THE WEEKEND BY TELEPHONE.

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RECOGNIZE THE SECOND STEP: "We came to believe that a Power greater than ourselves could restore us to sanity."

III. PRE-VOCATIONAL PHASE (two months) Upon completion of the Engagement Phase of the program, the peer enters the pre-vocational phase, adding on to what they have learned in Orientation and Engagement. For the next two months, peers will be focusing on the following: ~

Continuing to pursue the goals of engagement while exploring educational and vocational goals.

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Attend the pre-voc group.

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Begin to think about interests and explore their feelings about school or career.

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Building self-motivation.

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Objective I Understand program phases and stages of recovery (cont.) Handout I.1. continued For Perinatal mothers: ~

Learning to balance one's own needs with needs of children and family, emphasizing recovery to be one of the peer's family's needs.

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Increasing sense of empowerment and self-esteem.

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Improving coping skills. IMPORTANT BEHAVIORS TO BE LEARNED DURING PRE-VOCATIONAL PHASE: (Developing positive behaviors)

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HAVE A SPONSOR AND HOME GROUP: Keep a schedule of weekly meetings attended.

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HAVE A PHONE NETWORK.

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ACHIEVE A LEADERSHIP ROLE ON THE JOB LADDER: Become an Assistant Department Head, Expediter, Assistant Encounter Master, or Department Head.

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BE A POSITIVE ROLE MODEL: Express one's feelings responsibly. Describe how one feels without using street language or threats.

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SHOW RESPONSIBLE CONCERN BY REACHING OUT TO PEERS: Do this by sharing one's experience.

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INCREASE ABILITIES TO SELF-DISCLOSE: Every peer is expected to tell his/her your story.

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INCREASE SELF-ESTEEM: Take a pull-up without blowing one's stack, present oneself in a respectful manner (neat, clean, and well-groomed). Go the extra mile in performing one's job functions.

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BE RESPONSIBLE FOR ONE'S FINANCES: Develop a budget with the counselor or housing case manager.

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HAVE A DAILY PLANNER/CALENDAR APPOINTMENT BOOK: The member is expected to carry it always and keep track of personal appointments, activities, and medications.

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Objective I Understand program phases and stages of recovery (cont.) Handout I.1. cont. •

RECOGNIZE THE THIRD STEP: "We made a decision to turn our will and our lives over to the care of God as we understand him.”

IV. RE-ENTRY PHASE (three months) Peers are ready for the Re-Entry phase when they have maintained abstinence and demonstrated a commitment to the values of a drug-free life. Adding on to what they have learned in the previous phases, during the next three months they will be preparing to assume their roles as responsible, productive members of society. In order to reach this goal they must focus on the following: ~ Participate in the weekly Re-Entry group. ~ Participate in the weekly S.H.A.R.E. group. ~ Meet weekly with their vocational-rehab counselor to undergo education/work skills assessment and prepare to pursue their educational and employment goals. ~ If they want to be considered for Work Development they must demonstrate the following job skills: Perfect attendance and punctuality. ~ If appropriate, they will prepare for the responsibilities of being parents. For Perinatal mothers: ~ Assess ability to take on parenting responsibilities of children in foster care. ~ Learn to balance family responsibilities, voc-rehab, and recovery. During Re-Entry they may spend less time at Recovery Clinic. Nevertheless, they will be expected to be role models and assume positions of leadership. If they are working, they are expected to be at their work-site three days a week and in the program two days a week. IMPORTANT BEHAVIORS TO BE DEMONSTRATED DURING RE-ENTRY PHASE: •

BEWARE OF THE “WELLNESS SYNDROME”: Keep recovery their # 1 priority. Attend at least four to five meetings outside the program Monday through Friday and attend at least one meeting on the weekends.

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MAINTAIN REGULAR WEEKLY CONTACT WITH SPONSOR. 14

Objective I Understand program phases and stages of recovery (cont.) Handout I.1 cont. •

MAINTAIN GRATITUDE AND HUMILITY FOR SOBRIETY: Know the difference between abstinence and sobriety. They will be asked to assume a variety of positions within the community job ladder which will allow them to see how far they have really come.

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APPLY FOR ANY APPLICABLE WORK DEVELOPMENT OR JOB TRAINING PROGRAM (i.e., VESID)

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RECOGNIZE THE FOURTH STEP: "We made a searching and fearless moral inventory of ourselves."

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RECOGNIZE THE FIFTH STEP: "Admitted to God, ourselves and to another human being the exact nature of our wrongs."

V. AFTERCARE PHASE (four to six months) Advancement to this phase indicates that peers have made the transition from attending the day treatment program to pursuing personal goals in the community. As their lives becomes more rewarding, peers may also encounter stresses and complications. They will no longer have the intense support of the Recovery Clinic community. From now on it will be up to them to apply what they have learned in the Recovery Clinic to staying drug-free. In order for peers to adjust to living drug-free at this phase they are expected to do the following: ~

Attend the weekly transition group where they will discuss each others progress and problems. During this time they will give each other feedback and support each other's abstinence.

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Submit weekly urines. IMPORTANT BEHAVIORS TO BE DEMONSTRATED DURING TRANSITION PHASE:

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ASSUME RESPONSIBILITY FOR COORDINATING THEIR OWN MEDICAL CARE.

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ACTIVELY PURSUE WORK, SCHOOL, AND PARENTING RESPONSIBILITIES.

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ASSUME A LEADERSHIP ROLE IN A SELF-HELP OR RECOVERY GROUP IN THEIR COMMUNITY OUTSIDE BELLEVUE HOSPITAL.

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GET INVOLVED IN COMMUNITY ACTIVISM (i.e.,vote, join a block association, etc.) 15

Objective I Understand program phases and stages of recovery (cont.) Handout I.1 cont. •

RECOGNIZE THE SIXTH STEP: "Were entirely ready to have God remove all these defects of character."

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RECOGNIZE THE SEVENTH STEP: “Humbly asked Him to remove our shortcomings.”

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Objective I Understand program phases and stages of recovery

Summary By the end of this section trainees should understand the Recovery Clinic Program phases and their association with stages of recovery. They also should be aware of TC specific vocabulary and be able to describe aspects of the program in such terms. Summarize the section by noting the following: Objective I offered a general understanding of the program phases and stages of recovery, thereby laying the structure for the therapeutic milieu. This was accomplished by detailing specific sequences of the treatment program (i.e., orientation, stabilization, prevocational, aftercare/reentry) and tasks associated with each phase. Now we will address how the principles of self-help are incorporated into this overall structure (Objective II).

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Objective II Understand and promote self-help and mutual help Estimated time for delivery: 1 hour 40 minutes Trainer Note The underlying philosophy of the treatment model is that the peers themselves are the most significant change agents. The role of staff is to support peers' sense of competence and facilitate their leadership skills through graded responsibilities. Thus, the professional staff are charged with refraining from playing the role of "expert", which would undermine the role of the peers in themselves taking a leadership role. The staff's role is to provide the safe structure in which such self-help and mutual help will unfold. Content The professional's role in the self-help ambulatory treatment program is as follows:

< introduces each peer to the treatment community and establishes the linkage with a "big sister" or "big brother" in the program; < assesses the psychosocial needs of each peer (i.e., housing, entitlements) and provides the necessary level of ongoing guidance and support so that the member can best pursue whatever steps are indicated; < monitors all peer-conducted treatment groups to ensure that a prosocial environment is maintained at all times; < provides psychoeducational interventions to inform peers regarding their own management of their psychiatric and addiction-related symptoms and promotes them as competent consumers of mental health (e.g., identifying warning signals that professional help is needed). The trainer during a 30 minute lecture reviews information concerning psychoeducational group sessions (see handout II.1), common dangers that increase risk for relapse (see handout II.2), symptoms leading to relapse (see handout II.3), and behaviors indicating preparation for relapse (see handout II.4) below. Exercise Entire training group will be asked to brainstorm all clinic functions, including leadership of groups. Then, all functions will be classified according to the dimension of whether peer vs. staff leadership is necessary.

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Objective II Understand and promote self-help and mutual help Handout II.1 Psychoeducational Group Sessions At Recovery Clinic participation in various groups is emphasized. Each group focuses on crucial issues related to addiction and recovery. Purpose of groups: • Provide structure • Educate • Provide mutual support and a sense of community • Lead to improved self-awareness COMMUNITY MEETING - Forum for peers and staff to discuss community issues as they arise during the course of the program. At this time the monthly social is planned as well as other social events (i.e. Thanksgiving, Christmas socials, graduation celebration.) The purpose is to encourage peers to interact, discuss and resolve problems, and build decision making skills. ENCOUNTERS - The purpose of this group is to heighten individual/group awareness of specific attitudes and behaviors through responsible confrontation. The encounter provides a forum for participants to express feelings about themselves and each other, channel community friction and express community concern and support. EXECUTIVE MEETING - A weekly meeting with community leaders and staff to discuss issues concerning the community and program functioning. HOME GROUP - Weekly meeting with primary counselor to discuss various issues. HOUSE MEETING - Held the last fifteen to twenty minutes of the day. All peers must attend unless excused by their counselors. The meeting is run by senior peers (coordinator and expediters). The purpose is to apply social pressure in order to encourage individual change. This is done by public acknowledgment of positive or negative behavior in the community. Announcements that are made generally deal with pull-ups, adherence to contracts, and public commitments to behavior change. Those peers who have appointments or job changes to take place the following day, may make announcements during this time. INFANT STIMULATION - Supervised by a Child Development Specialist, this group provides age appropriate developmental activities for the infants while their mothers are attending Encounter groups. MONTHLY SOCIAL - Once per month the clinic will participate in a social event or activity which promotes unity among peers and offers an opportunity to learn how to socialize without using drugs. Birthdays can be celebrated at this time. The Hospitality Crew is responsible for the monthly collection of dues ($2) which is used in planning and carrying out the event. The events are the responsibility of the community with support from staff. 19

Objective II Understand and promote self-help and mutual help Handout II.1 Psychoeducational Group Sessions (cont.) MORNING MEETING - Community run meeting to begin the day on a positive note with fun and energy. PATIENT SEMINAR - Medical director (or other staff) speaks on psychological and medical aspects of addiction and recovery. PERINATAL PARENT CHILD DYAD - Combines developmental information and activities with supportive counseling around the emerging role of motherhood. Led by the Child Development Specialist. PERINATAL PARENTING SKILLS - Practical educational information for parenting children while peers are in recovery. PSYCHO-EDUCATION - Exploration of issues of concern to those who have a mental illness in addition to an addiction. RE-ENTRY - Exploration of individual goals and interests in area of school and career/job training. Report on individual progress. Discussion of issues specific to this phase of recovery (re-entry into community). RELAPSE PREVENTION - Education - Discussion of relapse as a process; Post-Acute withdrawal signs and symptoms; Substance abuse education; Relapse prevention techniques. SELF-DISCLOSURE - Group in which a peer of the community shares his/her drug experience and its consequences, struggles with recovery and hopes for the future. SELF-HELP ADVANCED RECOVERY (S.H.A.R.E. group) - For peers in Re-Entry phase of treatment. The purpose is to establish ongoing connections to peers who have achieved a stable level of abstinence. Peers work on tasks of "living life on life's terms" and "giving back" what they have learned. STRESS MANAGEMENT - Dealing with stress in early recovery; relaxation and meditation techniques are used to develop and enhance healthy coping skills. TRANSITION GROUP - For peers who have completed the day program. In this phase of treatment, peers continue to work on individual goals in areas of education and career. TWELVE-STEP GUIDELINES - Introduction to the 12 step concept, the disease of addiction and need for treatment. This is a time to review one's experiences with drugs and alcohol and one's attempts to deal with it alone leading to concepts of powerlessness, Higher Power, etc. 20

Objective II Understand and promote self-help and mutual help Handout II.1 Psychoeducational Group Sessions (cont.) WEEKEND PLANNING - Preparation for and structuring of peers' weekends. Utilization of time and recovery tools to prevent relapse. Reporting of any possible triggers one may encounter and strategies to deal with them. WEEKEND PROCESS - Review of weekend activities, discussion of relapses, near relapses: socializing while in recovery.

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Objective II Understand and promote self-help and mutual help Handout II.2 PUTTING ONESELF AT RISK FOR RELAPSE THE TEN MOST COMMON DANGERS 1. Being in the presence of drugs, drug users, or places where one used to cop or get high. 2. Negative feelings, particularly anger, but also sadness, loneliness, guilt, fear, and anxiety. 3. Positive feelings that make one want to celebrate. 4. Boredom. 5. Getting high on any drug. 6. Physical pain. 7. Listening to war stories and just dwelling on getting high. 8. Suddenly having a lot of cash. 9. Using prescription drugs that can get one high even if used as prescribed. 10. Believing that one is finally well - that is, no longer stimulated to crave drugs by any of the above situations, or by anything else - and, therefore, feeling that it is safe for one to get high occasionally. Called “The Wellness Syndrome” by peers.

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Objective II Understand and promote self-help and mutual help Handout II.3 A Check List of Symptoms Leading to Relapse •

Exhaustion

Allowing oneself to become overly tired and/or unhealthy. Good health and enough rest are important. If one feels well, one is more apt to think well. If one feels poorly, one may not think clearly. If one feels bad enough, one might begin to think that a drink and/or drug couldn't make things any worse. •

Dishonesty

This begins with peers exhibiting a pattern of unnecessary lies and deceits with peers, friends, and family. Then come important lies to oneself or "rationalizing"-- making excuses for not doing what one knows one should do. •

Impatience

Things are not happening fast enough. Others are not doing what they should be doing or what one wants them to do. •

Argumentativeness

Arguing small and ridiculous points indicates a need to always be right and expecting others to agree with one's own opinions. Peers may look for an excuse to drink or use drugs? •

Depression

Unreasonable and unaccountable despair may occur in cycles and should be dealt with -- talked about. •

Frustration

Feeling discouraged because things may not be going one's way. Everything is not going to be just the way one wants it. The peer may express thoughts suggestive of the following: • Self-pity "Why do these things happen to me? .Why must I be an addict/alcoholic?" "Nobody appreciates all I am doing -- (for them?)"

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Objective II Understand and promote self-help and mutual help Handout II.3 A Checklist of Symptoms Leading to Relapse (cont.) •

Cockiness

Got it made. No longer fear addiction. Going into drinking/drugging situations to prove to others they have no problem. •

Complacency

"Drinking was the furthest thing from my mind. Not drinking/using was no longer a conscious thought either". Peers are encouraged to be vigilant. They are advised that always having a little fear is a good thing; more relapses occur when things are going well than otherwise. •

Expecting too much from others

"I've changed: why hasn't everyone else?" •

Letting up on disciplines

Prayer, meditation, daily inventory, AA attendance may be discontinued by the peer stemming either from complacency or boredom. •

Use of mood-altering chemicals

Peers may feel the need to ease things with a pill or alcohol, and get a doctor to prescribe medication or the member may self-medicate with alcohol. •

Wanting too much

The peer may set goals that are beyond their reach. Peers are advised that "Happiness is not having what you want, but wanting what you have." •

Forgetting gratitude

Peers may be looking negatively on their lives, concentrating on problems that still are not totally corrected. Peers are advised to remember that it is good to remember where they started from -- and how much better life is now!

24

Objective II Understand and promote self-help and mutual help Handout II.3 A Checklist of Symptoms Leading to Relapse (cont.) •

"It can't happen to me."

Peers are advised that this is dangerous thinking. Almost anything can happen to them, and it is more likely to happen if they get careless. Peers are reminded that they have a progressive disease, and that they will be in worse shape if they relapse. •

Omnipotence

This is exhibited when peers behave as if they have all the answers for themselves and others. No one can tell them anything. They ignore suggestions or advice from others. Relapse is probably imminent unless drastic changes take place.

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Objective II Understand and promote self-help and mutual help Handout II.4 Behaviors Indicating Preparation for Relapse The following statements made by peers are suggestive of preparation for relapse: •

I start taking on other people's work, neglecting my own.

•

I smile a lot - dishonest with my feelings.

•

I become argumentative.

•

I start playing old resentment tapes.

•

I don't share my depression with my friends.

•

I get cocky.

•

I stop following-up, don’t keep promises.

•

I become complacent.

•

I start expecting things of others, and resent it when they don't live up to my expectations.

•

I get into "should-ing" all over myself.

•

I stop praying and meditating.

•

I stop doing my inventory.

•

I become bored (and boring).

•

I lose my faith and become flooded with irrational fears.

•

I become scattered and can't concentrate.

•

I become judgmental. I stop accepting people for who they are, and start judging them because they are not what they “should” be.

•

I stop listening to that small, still voice.

•

I become a martyr.

•

I stop asking for help. 26

Objective II Understand and promote self-help and mutual help Summary By the end of this segment trainees should have an understanding of the nature of psychoeducational groups provided in the Recovery Clinic program and nature of roles that define professional staff member and peer. Trainees should also be prepared to aid peers in detecting signs of relapse. Summarize the section by noting the following: Objective II provided a rationale for staff divesting themselves of the role of "expert". The distinction between staff and peer leadership of clinic functions was clarified. The next step in training builds on this new way of staff conceptualizing their role. Trainees are encouraged to see themselves as agents of positive behavioral change by themselves learning and adhering to the rules of the therapeutic community.

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Objective III Understand and practice positive role modeling Estimated time for delivery: 1 hour Trainer Note Present a sample of behaviors including appropriate and inappropriate behaviors to stimulate discussion and debate (see handout III.1 below)

Content The TC model emphasizes role modeling as a means of learning drug-free behaviors, by exposing the newly abstinent to a full spectrum of recovering peers, ranging from recovering senior peers on down to those peers who have a more short-lived, drug-free lifestyle. This emphasis on learning prosocial behavior through direct modeling, observation, and vicarious learning is consonant with a social learning/behavioral orientation (Bandura, 1969, 1971). As modeling procedures have been found to be most effective when the discrepancy between the observer and model is minimal, the availability of community role models with graded periods of abstinence and pro-social behavior may enable highly effective modeling for peers at all phases of recovery. The trainer will present a 30 minute lecture concerning the theoretical basis and empirical evidence for the role of positive role modeling in addictive behavior change.

Exercise A round robin exercise will be conducted in small groups of five. Each trainee will identify a behavior of his/her own that might conflict with the behaviors sanctioned by the treatment program and identify how they intend to correct this behavior. Three rounds will be conducted. Examples: tendency to intervene prematurely when a peer is upset; use of profanity; showing up late for meetings; negative body language.

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Objective III Understand and practice positive role modeling Handout III.1 Appropriate and Inappropriate Behaviors

APPROPRIATE BEHAVIORS

INAPPROPRIATE BEHAVIOR

*Attendance *Punctuality *Dress appropriately *Attend to personal hygiene *Self-Disclosure *Listening to others *Reach out to peers *Respect for authority *Frustration tolerance *Honesty *Take responsibility for yourself *Be self-motivated *Be a positive role model *Learn to manage your money *Complete job tasks *Turn in urines on time *Attend outside 12 step meetings *Learning rules of the program *Maintain confidentiality *Maintain gratitude and humility over sobriety

*Absences *Lateness *Wearing tight, revealing clothing *Neglecting personal hygiene *Monopolizing/disrupting group *Cutting off others *Isolating self and others *Disrespecting others *Acting out frustrations *Lying, stealing *Refusing responsibility *Keeping a street image *Profanity *Borrowing or lending money to peers *Abusing drugs/alcohol *Acts of violence or threats of violence *Engaging in sexual/romantic relationships with peers

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Objective III Understand and practice positive role modeling Summary By the end of this segment, trainees will have a comprehensive understanding of appropriate and inappropriate behaviors for the therapeutic milieu of the TC. Each trainee will be able to identify at least one of their own behaviors that might conflict with the treatment program and a specific strategy for remedying this behavior will be developed. Summarize the section by noting the following: Objective III was targeted to improved understanding and practice of positive role modeling of trainees. This objective built upon the earlier objectives of trainees learning the rule of the treatment community (Objective I) and appreciating the value of patientpeers assuming a role of self-help and mutual help (Objective II). As part of Objective III, staff-trainees developed a greater awareness of their own specific behavioral traits as they might impact on the functioning of the program, as well as formulating a plan for corrective action (as needed). With this awareness trainees will be ready for Objective IV, an understanding of the concept of "no we-they dichotomy". Objective IV continues the development of trainee awareness of their own behavior, again with the purpose of promoting an attitude that will support the treatment goals.

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Objective IV Understand and Promote the Concept of "No We-They Dichotomy" Estimated time for delivery: 1 hour, 30 minutes Trainer Note The professional-peer relationship in a peer-led treatment program is different than in more traditional mental health settings. While the professional is expected to impart his/her specialized expertise in the service of the treatment program and particular peers, he/she must also be careful to not reinforce status differentials to encourage peers to view themselves as "less than". Content The TC milieu does not tolerate a “we-they dichotomy” between professional staff and recovering peers. Although some individuals may know more than others in certain areas, e.g. professional expertise, and thereby be expected to contribute from this knowledge base each community member is expected to maintain an attitude of respect for all other members. Both staff and peers work collaboratively in promoting the concepts of personal growth. A common challenge that faces all people, whether mental health practitioner or person coping with mental illness and chemical addiction, is the conflict between short-term gratification and long-term well-being. In the case of the dually diagnosed individuals targeted for our treatment program, this conflict is manifested as "I need the drugs now... I need relief" vs. long-term goals of stability in housing, family functioning, etc. Staff may be less aware that they too face such conflicts in their own life. For example, any person who has attempted to make any significant behavioral change (e.g., losing weight, embarking on an exercise regimen, attempting to quit smoking) has faced this battle between short- and long-term comfort. The ability to forego short-term gratification in the service of long-term needs is an essential coping skill common to all. Such an understanding helps to destigmatize the individuals seeking treatment for chemical addiction in underscoring common properties involved in all behavioral change. The trainer presents a 30 minute lecture concerning the “no we-they dichotomy”. Exercise The following exercise explores experiences in habit change of the staff trainees, with emphasis on setbacks that occurred along the way. Heightening attention of staff to their own setbacks and relapses is important in promoting empathy towards the peers' struggle with chemical addiction. This exercise is conducted in the large group. The facilitator asks the group: "Think about the last time you tried to change your behavior. Did you succeed the first time? What challenges did you face? Where there any setbacks? Describe." 31

Objective IV Understand and Promote the Concept of "No We-They Dichotomy"

Summary By the end of this segment trainees should be more aware of their own conflicts in initiating and maintaining behavioral change and be more empathic to the struggles faced by persons in recovery. Summarize the section by noting the following: The TC model places a great emphasis on sharing an attitude of humility towards behavioral change, regardless of professional discipline. Objective IV promoted this common attitude by challenging trainees to explore their own difficulties as they have attempted to introduce habit change into their own lives (e.g., quit smoking, start exercising, etc.). Following Objective IV, trainees will have developed a greater humility about the struggle to effect positive habit change in their own life. With a greater appreciation of the accomplishment that peers make in the course of recovery, our next step in training is Objective V, an understanding of the upward mobility and privilege system.

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Objective V. Understand and Promote Upward Mobility and the Privilege System

Trainer Note The program involves increasing privileges and more responsible job functions. This institutional mobility is meant to encourage peers to take a more active role, with the understanding that by so taking action, positive consequences are to be expected. Such a program of systematic graded reinforcement may counteract prior experiences peers may have had during which their actions were ineffectual ("learned helplessness") in producing positive consequences.

Content Consistent with the TC's self-help approach, all peers are responsible for the daily management of the facility (e.g. cleaning activities, meal preparation and service, maintenance, purchasing, coordinating schedules, preparatory chores of groups, meetings, etc.). In the TC, the various work roles mediate essential educational and therapeutic effects. Job functions strengthen affiliation with the program through participation, provide opportunities for skill development, and foster self-examination and personal growth through performance challenge and program responsibility. Recovery Clinic program staff trainees are informed about the job hierarchy and behavioral principles underlying upward mobility and the privilege system in a 40 minute lecture given by the trainer. Trainees are then presented with a list of the positions (see handout V.1 ) and a description of the tasks assigned to each job function in a way that can be communicated directly to peers (see handout V.2).

Exercise Role play "resistance" to entrusting peers with increased job responsibilities (e.g., someone with mental illness symptoms, e.g., hallucinations, may be overlooked as participant on work crew).

33

Objective V. Understand and promote upward mobility and the privilege system Handout V.1 RECOVERY CLINIC JOB HIERARCHY COORDINATOR ENCOUNTER MASTER CHIEF EXPEDITER DEPARTMENT HEAD Service Hospitality Clerical Food Service EXPEDITER I & II ASSISTANT ENCOUNTER MASTER ASSISTANT DEPARTMENT HEAD Hospitality Clerical Food Service Service HOSPITALITY CREW CLERICAL CREW FOOD SERVICE CREW SERVICE CREW

34

Objective V Understand and promote upward mobility and the privilege system Handout V.2 Job Functions JOB FUNCTIONS All peers are assigned a job function within the program. These tasks provide peers an opportunity to: • improve work habits • develop a sense of responsibility • develop the ability to accept directions and authority • develop leadership skills • acquire better coping skills Each peer begins with the service crew and gradually assumes greater responsibility with higher job functions as he/she progresses in the program. As a peer moves up the job ladder it is that person’s responsibility to train the new peer who takes over his/her position. Individuals may be reassigned if another crew requires additional assistance. Each crew has a staff advisor. EVERYONE STARTS HERE! SERVICE CREW Responsibilities: Maintaining order and cleanliness in the clinic. Jobs include: 1. Sweeping and mopping the floors in the kitchen/coat room and group room. 2. Cleaning the chalkboard. 3. Arranging chairs for the next group when needed. 4. Stacking of chairs at the end of day. 5. Wiping windows in kitchen/coat room and group room. 6. Wiping off tables in kitchen/coat room and group room. 7. Cleaning refrigerator daily. 8. Defrosting refrigerator weekly. 9. Cleaning kitchen closet. 10. Clean microwave daily. 11. Straightening paper organizer in group room. 12. Cleaning shelf top of radiator. 13. Packing and taking-out garbage daily.

35

Objective V. Understand and promote upward mobility and the privilege system Handout V.2 Job Functions (cont.) After 30 days and a completion of your orientation contract, you are eligible for a promotion to one of the three crews: Food Service, Clerical or Hospitality. CLERICAL CREW Responsibilities: Keeping and updating records in the community. Jobs include: 1. Preparing attendance sheets for groups and circulating them for signatures. 2. Calling absent peers. 3. Giving staff "missing slips" on absent peers. 4. Putting all names and appointments on the monthly calendar. 5. Making sure that the office associate receives attendance sheets. 6. Taking minutes at community meetings. 7. Preparing chalk board on a daily basis: Putting word of the day (w.o.d.) on board. Putting concept of the day (c.o.d.) on board. Putting names of peers on board who have appointments. Listing all those who are late, sick or missing on board. 8. Making name plates for new admissions and posting under service crew section. FOOD SERVICE CREW Responsibilities: Using the transporter, the Department Head is responsible for picking up lunch upstairs. The crew, as a whole, is responsible for preparing the group room for lunch, serving/distributing food, and cleaning lunch area after meal. Jobs include: 1. Setting up tables. 2. Arranging utensils, cups, napkins and beverages. 3. Serving food. 4. Wiping tables after meal. 5. Washing pans. 6. Replacing pans in transporter. HOSPITALITY CREW Responsibilities: Welcoming and orienting new-comers to program. Distributing program information. Jobs include: 1. Planning and arranging the monthly social. 2. Collecting and keeping records of all dues. 3. Escorting peers to and from inpatient wards, emergency room and appointments (as directed by staff). 4. Monitoring and supervising activities of peers who are auditing the program. 36

Objective V. Understand and promote upward mobility and the privilege system Handout V.2 Job Functions (cont.) Continued progress leads to the opportunity to become a community leader! ASSISTANT DEPARTMENT HEAD Responsibilities: Reporting to and assisting Department Head in ensuring performance of all department job responsibilities. "Acts as" head of department in absence of head. DEPARTMENT HEAD Responsibilities: Providing leadership and overseeing crew. Delegating work and ensuring that work is being done with Assistant Department Head. Being available to assist crew as necessary. Supervising performance of task, following-up to ensure work is done. Attends Executive Meeting. EXPEDITER I & II Responsibilities: Acting as the "eyes and ears" of the community. Recording all information collected in expediter book. Monitoring and directing peer and community activities, including getting peers to groups on time. Reading daily record during House Meeting. CHIEF EXPEDITER Responsibilities: Supervisor of Expediter I and II. Meeting with expediters on a weekly basis to coordinate performance of responsibilities. Acting as expediter in absence of Expediter I and II. Attending Executive Meetings. ASSISTANT ENCOUNTER MASTER Responsibilities: Training position as preparation for becoming Encounter Master. Assisting Encounter Master in running of encounter groups and running encounter in Encounter Master’s absence. ENCOUNTER MASTER Responsibilities: Facilitating encounter groups under the supervision of staff. Responsible for encounter slips (prioritizing slips in order of importance, etc.). Acting as time-keeper and ensuring timely movement of the group. Attending Executive Meeting. COORDINATOR Responsibilities: Acting as the community leader. Reporting directly to the staff. Preparing agenda and leading Community Meeting. Gathering and presenting information on community status. Providing direct supervision of Departmental Heads, Assistant Department Heads and Expediter.

37

Objective V. Understand and Promote Upward Mobility and the Privilege System Summary By the end of this segment trainees should be aware of the program's job roles and functions, and managing special needs of individuals as they progress through the hierarchy. Summarize the section by noting the following: Objective V provided a full understanding of the specific job roles and functions, as well as the management of special needs of a program targeted to the dually diagnosed. With this understanding, trainees will be ready for Objective VI, an understanding of adherence to program rules.

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Objective VI Understand and promote adherence to program rules Estimated time for delivery: 2 hours

Trainer Note Administer pretest (see below).

Content The program involves adhering to rules and accepting behavioral disciplinary contracts. The consistency and stability in the program structure helps to foster a sense of the world as reliable and offers the chance for peers to practice negotiating skills within a community in which rules are applied fairly. Professional staff must be made aware of all program rules and regulations. In a 40 minute lecture the trainer presents information concerning program rules and regulations (see handout VI.1) as well as specific procedures related to morning meeting (see handout VI.2 ), encounters (see handout VI.3), and behavioral guidelines applicable to group sessions (see VI.4). The information contained in the handouts is worded in terms of the peer’s perspective.

Exercise Trainees will test their recall and presentation of program rules by breaking into dyads and role playing descriptions of program rules to each other. Administer post-test (see below).

39

Objective VI. Understand and promote adherence to program rules PRETEST Community Rules and Procedures Answer the following TRUE OR FALSE: 1) Urine bottles may be taken home by the peer. 2) Peers are permitted to leave group sessions for a few minutes and come back if they get angry. 3) Peers will be subject to discharge from Recovery Clinic for forming a romantic or sexual relationship with another peer. 4) Lending or borrowing money from peers is encouraged. 5) It's not considered a slip if a peer uses a drug different from the peer's drug of choice. 6) Morning meeting is the peers' time to have fun and build motivation for the day. 7) Rules and regulations are necessary to keep the community a safe place. 8) Peers may pay monthly dues if they want to. 9) A pull-up is a sign of responsible concern. 10) Outside meetings are not necessary because the peer can get all that is needed in the Recovery Clinic program. 11) A significant other makes a good sponsor. 12) If a senior peer is seen by a junior peer breaking a rule, the junior peer should not report it. 13) The counselor should be notified by the peer if the peer is going to be late or if an emergency comes up. 14) There are peers in Recovery Clinic who don't have a drug problem. 15) Not everyone starts out on service crew. 16) Breaking a contract is a serious treatment issue. 17) It is the peer's responsibility to stop someone from using drugs. 40

Objective VI. Understand and promote adherence to program rules PRETEST (cont.) 18) Smoking is permitted in the bathroom. 19) If the peer does not like a group, the peer does not have to attend the session. 20) Refusal to turn in a urine sample is considered a dirty urine. 21) The only time it is okay to insult someone's inborn dignity is during an encounter group. 22) Keeping someone else's secrets will not harm a peer's recovery. 23) Recovery is a process not an event. 24) It's okay to feel angry, but not to act out one's anger. 25) Senior peers know everything there is to know about recovery. 26) It's important for the peer to be on time and present because it will help the peer be successful in achieving a career. 27) Each peer is responsible for the results of his/her own decision. 28) It's not important for a peer to tell staff everything about the peer's health. 29) The program's phases of treatment in order are: Transition. Pre-Voc. Orientation. Re-entry and Engagement. 30) Rules are made to be broken.

Note: A post-test identical to this pre-test appears prior to the summary for Objective VI (pp. 51-52). The answer key appears in Appendix II (p. 64).

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Objective VI Understand and promote adherence to program rules Handout VI.1 Program Rules and Regulations Why do we have rules and regulations? •

For the efficient functioning of the program.

•

To provide consistent and fair treatment to all peers.

•

To inform peers of their responsibilities.

•

To ensure that irresponsible behavior on the part of an individual will not jeopardize the treatment of the other peers. So the community will be a safe place to come to.

Anyone who cannot or will not follow these rules is not appropriate for treatment at this program. Violation of any of the rules and regulations will result in a warning and mandatory self-disclosure before the community. Repeated non-compliance will lead to suspension, probation, and possible termination. Input from community representatives is important and will be taken into consideration. However, staff will decide which consequences are appropriate. 1) TOTAL ABSTINENCE •

Continued drug or alcohol use is prohibited. It is expected that upon enrollment in the program you have made a commitment to stop using all abusable substances.

•

By committing to total abstinence you agree not to expose yourself or your peers to situations which are likely to lead to picking up. An obvious example is going to a bar/club where alcohol or drugs are available. Such behavior indicates denial or other dangerous thinking. Your peers, as well as staff, will confront you about this kind of behavior. Your feelings and rationalizations prior to picking up will be explored. If you continue to violate this rule, you are telling peers and staff that your commitment to abstinence is questionable. In that case, staff will decide on appropriate consequences (suspension, probation, or termination).

2) URINE TESTING •

Urine is to be turned in before the first group begins. This means between 9:00 and 9:30. For late arrivals, urines may be turned in between 12:15 and 12:30 only. If you miss both collection times, you can turn your urine in only to your individual counselor.

•

Peers absent on a urine collection day are responsible for turning in a sample on the next day.

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Objective VI Understand and promote adherence to program rules Handout VI.1 Program Rules and Regulations (cont.) •

Failure (forgetting) or refusal to turn in a urine sample will be considered equivalent to a dirty urine.

•

Under no circumstances is a urine bottle to be taken from the clinic area.

•

Remember that recovery requires honesty to self and others. If you have picked up, inform your counselor and peers immediately so that they can help you learn from your mistake and support your recovery.

C

Procedure for a dirty urine: 1) Drop a slip on yourself. 2) Service crew for 2 weeks. 3) Daily urines for 2 weeks.

No exceptions to the rule! Remember: Lab errors are extremely rare. It is much more likely that your disease made you pick up and is making you deny it. It's not that we don’t trust you - we don't trust your disease. We would rather risk making a mistake and treat you unfairly than risk your recovery. 3) ATTENDANCE AND PUNCTUALITY •

Daily attendance is required and you must be here on time! You must register and sign in daily. This is proof of your attendance and punctuality - not just for carfare reimbursement.

•

If you have an emergency, unavoidable lateness or absence, you must call in that morning and speak directly to your counselor.

•

If you have appointments, notify both your counselor and clerical crew in advance.

•

Appointments should be scheduled after program hours whenever possible. Any exceptions should be cleared with your counselor.

•

You will be required to provide documentation for appointments, absences, or if you come to the program late. In addition, if you are late to a group you must obtain a slip from your counselor to join that group.

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Objective VI Understand and promote adherence to program rules Handout VI.1 Program Rules and Regulations (cont.) •

Once you arrive, you may not leave the clinic without permission until the program ends. This includes celebrations, socials and outings.

4) PROGRAM •

Participation in all groups and other activities is mandatory. This includes field trips and events scheduled by the clinic, one-on-one sessions with your counselor which may occur after program time, outside NA/AA meetings, phone contracts with your peers etc. RECOVERY DOES NOT END AT 2:00 P.M. IT IS A CONTINUOUS PROCESS!

5) ANY ACTS OF VIOLENCE AND/OR THREATS ARE PROHIBITED •

This will result in automatic termination.

6) NO FINANCIAL TRANSACTIONS OR SOLICITATIONS •

No borrowing or lending money. This can lead to negative contracting.

7) NO ROMANTIC OR SEXUAL RELATIONSHIPS WITH PEERS •

All peers must be treated as members of your family. Violation of this rule undermines not only your recovery but also the community's recovery. If you have sex or form a romantic relationship with a peer of the Recovery Clinic community you will be discharged from the program.

8) TELEPHONE USE •

Use of office phones is restricted. The clerical crew may have access to staff phones at a specified time to contact absentees. Counselors phones may be used with their permission.

9) PRESCRIPTIONS/MEDICATION •

Speak with the nurse or medical director before you run out of medication. Arrangements will be made to get prescriptions to you promptly with your counselor.

•

You are to inform the nurse of ALL medications that you are taking.

•

It is also your responsibility to inform your physicians and dentists that you are in recovery and narcotic or other addictive substances should be prescribed with caution. Please notify your counselor if you are prescribed any medications. 44

Objective VI Understand and promote adherence to program rules Handout VI.1 Program Rules and Regulations (cont.) 10) APPEARANCE AND PERSONAL HYGIENE •

Your appearance and presentation is an extension of yourself. It is an indication of how you feel about yourself and how others will perceive and interact with you. Respect yourself and have consideration for those around you. Dress appropriately and practice cleanliness. Please do not dress in a sexually provocative manner. DRESS CODE: * * *

Skin-tight skirts or shorts exposing underwear and skin are inappropriate. Tights or stretch pants should be worn with a long top to cover behind. No see-through or transparent tops exposing brassiere or skin.

11) PROFANITY IS STRONGLY DISCOURAGED • Remember there are children in the community. 12) CONFIDENTIALITY •

Self-disclosure is an important element of recovery. Self-disclosure is inhibited when the community cannot be trusted to keep sensitive information within the program. This means no gossiping or using information maliciously.

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Objective VI Understand and promote adherence to program rules Handout VI.2 Procedures Relating to Morning Meeting PURPOSE: When we were using drugs, we did what we felt like doing when we felt like doing it. We were only interested in taking care of our wants and we neglected our needs. It didn't work. Today we are learning in our treatment to build a structure in our lives. A good structure sets aside time for all of our needs: A time to eat, a time to sleep, a time to work, and a time to play. This is our time to play. And in our play we build our motivation to do the hard work our recovery requires of us in our groups. We learn how to interact with others and discover that we are not alone. For the first time in our lives we are part of something larger than ourselves--our community; we know that what we were never able to do for ourselves is starting to happen--together, within our structure. PLANNING: Planning the morning meeting is absolutely essential. Leaders of the morning meeting should be selected at least a week before hand so that they have time to prepare and have their plans reviewed by staff. The success of the morning meeting depends upon the time and care spent on its preparation. While the specific activities may vary, the following elements are usually included: •

SERENITY PRAYER

•

WEATHER

•

CONCEPT: a single concept is presented each day. It incorporates the "word of the day". The Group leader will give a one or two minute explanation - especially from his/her own experience.

•

SKITS, JOKES and/or MOCK AWARDS: These always need to be upbeat and positive -never at someone's expense.

•

SONGS or GAMES

•

Close with reciting RECOVERY CLINIC PHILOSOPHY (See Appendix II.B).

RULES: 1)

One is never forced to do something he/she does not want to do.

2}

Activities should be done for fun, not for negative responses and should never be confrontational. Save confrontations for encounters. 46

Objective VI Understand and promote adherence to program rules Handout VI.3 Procedures for Encounter Sessions THERE ARE 3 STAGES TO THE ENCOUNTER: The THREE C's : CConfrontation CConversation CClosure The Encounter should be 15 minutes in total. 1) CONFRONTATION: Any peer can be confronted about a specific behavior or attitude (a collection of thoughts, feelings and behaviors). PURPOSE: To see oneself more objectively, although it may be painful or uncomfortable. LIMIT: 5 minutes 2) CONVERSATION/QUESTIONS: The confronted person is given a chance to respond to the confrontation. The Encounter Master says, "The group is on you. Tell us how you feel." PURPOSE: To explore reasons behind the behavior and associated feelings and to make a commitment to change the behavior. LIMIT: 5 minutes PROCEDURE: A.

If necessary, questions can be asked of the confronted person to break through denial.

B.

Questions come from the INNER CIRCLE first.

C.

After the confronted person responds, the person who dropped a slip can ask a question of the confronted person. The confronted person then responds to this question. If the person asking the question is not satisfied with the response, then he/she can ask a second question.Then move on to the next person.

D.

Limit of 2 questions per person. However, if Encounter Master deems it necessary, he/she can allow more questions.

E.

The Encounter Master decides if questions will be permitted from people in the OUTER CIRCLE.

F.

The Encounter Master will follow the order of calling on people who dropped a slip first, then go to the rest of the INNER CIRCLE, then the OUTER CIRCLE.

G.

If confronted person responds fully, questions should not be necessary. 47

Objective VI Understand and promote adherence to program rules Handout VI.3 Procedures for Encounter Sessions (cont.) 3) CLOSURE/FEEDBACK: The person confronted is now given feedback by the group. Feedback comes in the form of comments from people who can identify with the problems or issues and who can explain how they have dealt with these problems, issues or feelings in the past. PURPOSE: To be supportive of the encountered person. LIMIT: 5 minutes On the day of the Encounter, the Encounter Master (under staff supervision) will set up the group to be in the INNER CIRCLE. The INNER CIRCLE consists of: • • • • •

The Encounter Master The Assistant Encounter Master All the people with slips dropped on them All the people dropping slips Person(s) representing peer strength in the community.

The group should number 13 to 15 people. If too many slips have been dropped, the Encounter Master will prioritize the slips and select those slips to be honored that day.

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Objective VI Understand and promote adherence to program rules Handout VI.4 ENCOUNTER RULES

•

No physical violence or threats of physical violence.

•

No leaving your seats.

•

No rat-packing (collective assault on one peer.)

•

No red-crossing (playing lawyer for the person being confronted.)

•

Use honesty (not just a tit-for-tat.)

•

Show responsible concern for the person being confronted.

•

Confidentiality - information learned in the encounter groups is to be used supportively within the community. This means no gossiping or using information maliciously.

•

No walking out of group.

•

No cross talking.

•

During the encounter one must respect the Encounter Master. This may mean that one has to hold one's belly.

•

Anyone can disagree with the Encounter Master when the group is over.

PEOPLE WITH APPOINTMENTS DURING ENCOUNTERS SHOULD SIT NEAR THE DOOR AND EXIT QUIETLY.

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VI. Understand and promote adherence to program rules Handout VI.5 Behavioral Guidelines While Group is in Session While group is in session, please observe the following rules: l ) Get involved! Share your feelings, especially those that bother you. Talk about any urges, cravings, slips and other changes you are experiencing. But please, no monopolizing. 2) No talking with your neighbors No cross talking or other disruptions, including getting up from your seat and walking around the room. Consequences: A) You will be given a pull-up B) You will be asked to apologize to the community C) If you refuse to apologize, you will be asked to leave the group D) Coordinator or expediter will get medical director if necessary 3)

No going to bathroom. Try to go during break time. Exceptions only with medical note: (i.e. pregnancy, changing baby, etc.)

4)

Sit close to the door if:

A) Coming in late B) Leaving early SEATS ARE TO BE LEFT BY THE DOOR FOR LATE-COMERS.

5)

Late-comers: A) Come in quietly B) More than l0 minutes late: LISTEN ONLY

6)

No eating or drinking in group.

7)

Dress Code:

8)

No walking out of group. Consequences: Scenario #1: A) See counselor before going back to any group B) Drop a slip C) Apologize to the community Scenario #2: A) Emergency: send expediter or group leader

9) 10) 11) 12)

Expediter will sit by the door. No sleeping in group. During Encounter Group, babies must go to Infant Stimulation. Counselors will not escort member back into group.

NO BEEPERS NO SUNGLASSES NO WALKMANS

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Objective VI. Understand and promote adherence to program rules POST-TEST Community Rules and Procedures Answer the following TRUE OR FALSE: 1) Urine bottles may be taken home by the peer. 2) Peers are permitted to leave group sessions for a few minutes and come back if they get angry. 3) Peers will be subject to discharge from Recovery Clinic for forming a romantic or sexual relationship with another peer. 4) Lending or borrowing money from peers is encouraged. 5) It's not considered a slip if a peer uses a drug different from the peer's drug of choice. 6) Morning meeting is the peers' time to have fun and build motivation for the day. 7) Rules and regulations are necessary to keep the community a safe place. 8) Peers may pay monthly dues if they want to. 9) A pull-up is a sign of responsible concern. 10) Outside meetings are not necessary because the peer can get all that is needed in the Recovery Clinic program. 11) A significant other makes a good sponsor. 12) If a senior peer is seen by a junior peer breaking a rule, the junior peer should not report it. 13) The counselor should be notified by the peer if the he/she is going to be late or if an emergency comes up. 14) There are peers in Recovery Clinic who don't have a drug problem. 15) Not everyone starts out on service crew. 16) Breaking a contract is a serious treatment issue. 17) It is the peer's responsibility to stop someone from using drugs. 51

POST-TEST (cont.) 18) Smoking is permitted in the bathroom. 19) If the peer does not like a group, he/she does not have to attend the session. 20) Refusal to turn in a urine sample is considered a dirty urine. 21) The only time it is okay to insult someone's inborn dignity is during an encounter group. 22) Keeping someone else's secrets will not harm a peer's recovery. 23) Recovery is a process not an event. 24) It's okay to feel angry, but not to act out one's anger. 25) Senior peers know everything there is to know about recovery. 26) It's important for the peer to be on time and present because it will help the peer be successful in achieving a career. 27) Each peer is responsible for the results of his/her own decision. 28) It's not important for a peer to tell staff everything about the his/her health. 29) The program's phases of treatment in order are: Transition. Pre-Voc. Orientation. Re-entry and Engagement. 30) Rules are made to be broken.

Note: A pre-test identical to this post-test appears at the outset of Objective VI (pp.40-41). The answer key appears in Appendix II (p.64).

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Objective VI Understand and promote adherence to program rules Summary By the end of this segment, trainees should achieve an understanding of program rules and regulations and how peers' adherence to such rules plays a role in recovery from addiction. Summarize the section by noting the following: With the completion of Objective VI, trainees will be ready for the final objective, VII, facilitation of communication with dually disordered to minimize resistance. In a program targeted to a patient population, some of whom are psychiatrically compromised, one can expect that at times peers will be inflexible on certain points. It is important that staff learn how to communicate with peers at such times in a flexible fashion so that conflict is reduced and the "spirit" of the program is followed.

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VII Facilitate Communication with Dually Disordered to Minimize Resistance Estimated time for delivery: 1 hour, 30 minutes

Trainer Note The self-help ambulatory program is adapted to the needs of the dually disordered. In addition to offering stability and structure, the program must also be flexible in meeting the individual needs of peers served. For example, not uncommonly peers may express "resistance", i.e., unwillingness to cooperate with some aspect of the program. As we are dealing with a dual diagnosed population, this resistance may be due to a rigidly held belief system rather than a lack of cooperation with some aspect of the TC model. For example, if a peer holds the belief that contact with a cleanser will cause him cancer, shifting his responsibilities to a clerical task might be an alternative acceptable to the treatment community. Staff trainees need to learn how to negotiate such communication breakdowns so the spirit of the program's rules is not compromised.

Content The trainer will discuss basic listening and conflict negotiation skills in a 20 minute lecture (see handout VII.1).

Exercise The group breaks up into dyads and role plays conversational exchanges involving confrontation.

Summary By the end of the segment, trainees will be more aware of how to decrease conflict by improving communication skills.

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VII. Facilitate communication with dually disordered to minimize resistance. Handout VII.1 Aiding Communication 1.

Listen. Try to put yourself in the other person's shoes and understand what she/he is thinking and feeling. It may help if you begin with one of these expressions in a gentle tone of voice: * "What you seem to be saying is ..." * "It sounds like ..." * "Let me see if I'm getting this right" * "I just want to make sure that ..." * "I understand what you're saying."

2. Question. In particular, you can ask the other person to tell you more about his/her negative feelings, since that's what most people are afraid to talk about. 3. Drop defensiveness when hearing criticism. Listen to find some truth in what the other person is saying, even if you feel convinced that what is being said is unfair. 4. Stroke. You can try to find something genuinely positive to say to the other person, even in the heat of battle. This indicates that you respect the other person, even though you may be angry with each other. How to end a standoff (neither of you will budge from your position) : 1. Genuinely try to see things from your partner's perspective. Don't "Yes-but". Summarize how you think your partner feels. 2. Communicate that you think your partner's perspective makes sense, is valid; even if you don't agree, you can both be right. 3. Be aware of the catastrophic expectations you are attaching to things. Tell yourself that you won't let these things happen. (An example of a catastrophic expectation is "If I give in, I will always be crawling to him.") 4. Ask your partner: "What can we do to make things better?" 5. State clearly and specifically what you will be willing to do to make things better. Present your recommendations in terms of a positive suggestion. Adapted from D. Burns. The Feeling Good Handbook, 1989 and Gottman et al. A Couple’s Guide to Communication, 1976. 55

Focus Groups A series of focus groups were conducted beginning in 1996 under the direction of the Recovery Clinic director, Carlotta Schuster, M.D. Through these groups staff arrived at a consensus of the general training principles and operationally defined the behaviors sanctioned within the ambulatory TC model. These focus groups were composed of treatment providers from the following disciplines: social work, psychology, psychiatry, addiction counseling, and nursing. A compilation of these focus group meetings was conducted by Aimee Trotter, the source material by which Drs. Helen Dermatis and Susan Egelko developed a training manual for staff.

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REFERENCES Bandura, A. Principles of behavior modification. Holt, New York (1969). Bandura, A. Psychotherapy based on modeling principles. In A.E. Bergin and S.L. Garfield (Eds.), Handbook of psychotherapy and behavior change. John Wiley, New York (1971). Burns, D. The Feeling Good Handbook. William Morrow and Company, Inc., New York (1989). DeLeon, G. Community As Method Therapeutic Communities for Special Populations and Special Settings. Praeger, Westport, Connecticut (1997). Egelko, S., Galanter, M., Dermatis, H., and DeMaio, C. Evaluation of a Multi-Systems Model for Treating Perinatal Cocaine Addiction, Journal of Substance Abuse Treatment, Vol. 15, No.3 (1998). Galanter, M., Dermatis, H., Egelko, S., and DeLeon, G. Homeless and Mental Illness in a Professional and Peer-Led Cocaine Treatment Clinic, Psychiatric Services, Vol. 49, No.4 (1998). Gold Award: Comprehensive Clinical Services for Substance Abuse Treatment in an Inner-city General Hospital, Hospital and Community Psychiatry, Vol. 44: 991-994 (1993). Gottman, J. Notarius, C., Gonso, J., & Markman, H. A Couple’s Guide to Communication. Research Press, Champaign, IL (1976). Kerr, D. The Therapeutic Community: A Codified Concept for Training and Upgrading Staff Members Working in a Residential Setting. In G. DeLeon and J.T. Ziegenfuss (Eds.), Therapeutic Communities for Addictions. Charles C. Thomas, Springfield, IL (1986).

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Appendix I.A Objective I Understand program phases and stages of recovery.

STAGES OF RECOVERY WITHDRAWAL 0-15 DAYS Some physical and psychological symptoms: • • • • • • • • • • • • • •

Feeling tired Having urges Nightmares Cold Sweats Insomnia Irritability Depressed Extreme Mood Changes Increased Appetite Poor attention span Headaches Feeling of no control Low body resistance Bad attitude HONEYMOON 16-45 DAYS

Symptoms: • • • • • • • •

Riding on a"pink cloud" Euphoria "Got it kicked" "Can handle it" Overconfident Optimistic Denial Think you can drink and drug

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THE WALL 46-120 DAYS Symptoms: • Depression • Isolation • Suicidal thoughts • Withdrawal • "Pink cloud life" • Anxiety • Self-loathing • Small commitments being made • Denial • Flashbacks • Physical strength returns • Reality sets in • Making new friends • Learning to love oneself • Self-doubt • Compulsion or desires to use again • Laziness • Disappointments • Boredom • Frustrations • Irritability • Danger of relapse • Leaving the program • Low self-esteem • Confusion • Pessimism • Emotionalism • Anger/Resentments • Awareness of Responsibilities • Seeking Rewards • Dishonesty • Relearning behavior patterns • Sexual disinterest/dysfunction • Clearer thinking ability • Trying to reestablish relationships

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ADJUSTMENTS 121-180 DAYS/4-6 MONTHS Common Behaviors: • Return to high risk situations • Decrease in abstinence promoting behaviors • "Return to normal life" Cognitive (Brain thinking): • Reduced frequency of cocaine (drug) thoughts and cravings • Questioning of addiction Emotional symptoms: • Reduced depression • Reduced anxiety • Reduced irritability • Continued boredom • Loneliness Relationship characteristics: • Emergence of long-term relationship problems • Resistance to assistance with relationship problems

RESOLUTION STAGE 180 DAYS - 6 MONTHS Common Behaviors: • Emergence of other excessive behaviors-gambling, sex, work, eating, alcohol use Cognitive: • Questioning the need for long-term monitoring and support Emotional Symptoms: • Conflict between recovery principles and relationship needs.

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Appendix I.B Objective I Understand program phases and stages of recovery GLOSSARY OF TERMS ACT AS IF - To assume a role or attitude even though you don't feel like it. ACTING OUT/REACTING - Impulsively expressing anger or hostility, verbally or through body language, in an inappropriate place and manner (i.e., kicking a chair or cursing at someone.) ATTITUDE - A collection of thoughts, feelings and behaviors. CONFRONTATION - Presenting a person with a description of his/her behavior and its effects, with a request that they explain it and/or change it. DENIAL - A sometimes healthy defense that is abused by addicts to avoid recognizing the realities of our disease. It differs from lying in that a lie is a conscious deception and denial implies a lack of awareness of reality. DROP A SLIP - Asking for a person to be in your encounter group by dropping a slip which has your name and his/her name on it, in the encounter box. DUMPING - To ventilating problems and concerns. FEEDBACK - Telling a person what you think about what they've said (i.e., in group.) GUILT - A feeling that stems from the violation of program rules and which is hidden from the community and staff. HOLDING YOUR BELLY - Putting up with a feeling until it is appropriate to express it. HONESTY - Admitting or revealing something. This can refer to disclosing something in group or getting rid of guilt. IMAGE - A style of self-presentation, (i.e., dress, verbal language, body language), used to impress and gain the acceptance of others. An image is often used as a shield to avoid showing one's real self to others, out of fear of rejection or manipulation. People often adopt and maintain an image in order to belong to and survive in a drug-oriented clique. ISSUE - A personal problem or difficulty that prevents a person from growing, (i.e., fear of speaking in front of a group of people.)

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NEGATIVE CONTRACT - Two or more people in the program who have a spoken or unspoken agreement to cover for one another. They may do so by condoning each other's guilt, not confronting one another in group, etc. PROJECTION - To see a characteristic in another person because you possess it yourself.

PULL-UP - Bringing another person’s behavior up to level by telling that person that he/she is doing something that is against the rules of the program, or is personally harmful. A pull-up is a sign of "responsible concern” for your peer and shows that you are your brother's keeper. PULLING YOUR WEIGHT - Taking responsibility for one's share of duties in the community. SLIDING - Going through treatment without being challenged and therefore not growing. STAFFED - Being aware of negative behavior and attitude by staff. This usually serves as a warning before other disciplinary measures are taken. STUFFING FEELINGS - Holding strong and painful feelings inside rather than expressing them in a manner in which they might be resolved. PERSONALIZING - Tending to think that the actions or statements of others are a personal attack when they are not. Being overly sensitive. UNCONDITIONAL LOVE - Love given no matter what the recipient does. Setting no limits, giving love to someone who has not earned it.

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Appendix I.C Objective I Understanding program phases and stages of recovery ORIENTATION PHASE CONTRACT You are being invited to come to the Recovery Clinic for an Orientation Phase of one month. During this time you are expected to comply with the following conditions: 1)

Attend program daily, Monday through Friday, 9:00 a.m. to 2:00 p.m.

2)

Submit urine daily for 2 weeks.

3)

Attend and participate in the program groups.

4)

Have a complete physical exam with blood work, EKG, Chest x-ray and PPD.

At the end of this time, the team will evaluate you for official admission to the program and assist you in determining your treatment goals.

I,________________________ agree to this evaluation period from __________ to __________.

_____________________________ Name

______________________________________ Signature Date

_____________________________ Witness Name

______________________________________ Witness Signature Date

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Appendix II.A Objective VI Understand and promote adherence to program rules

Pre- and Post-test Answer Key 1. F 2. F 3. T 4. F 5. F 6. T 7. T 8. F 9. T 10. F 11. F 12. F 13. T 14. F 15. F 16. T 17. T 18. F 19. F 20. T 21. F 22. F 23. T 24. T 25. F 26. T 27. T 28. F 29. F 30. F

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Appendix II.B Objective VI Understand and promote adherence to program rules

RECOVERY CLINIC PHILOSOPHY We are here because we realize that drugs have made our lives unmanageable! We have made a commitment to change for ourselves...For those we love...and for those who love us. No matter how difficult, we will succeed and take our rightful place in our community.

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