The D.E.C.L.A.R.E. MODEL
Dr. Purcell Taylor DABPS, LPCC,LICDC Full Professor of Psychology Department of Psychology University Of Cincinnati purcell.taylor@uc.edu 513-556-1681 Cell Phone 513-290-7908
Why develop a new model? l
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In my search for a new addiction model I was aware of many of the medical and psychosocial treatments being utilized for drug misuse, abuse and dependency that existed in the early 1980s and into the 1990s . However, many of these approaches did not address the issues confronted by individuals with drug and alcohol problems because they were not developed specifically meet the multidimensional needs of clients with problems involving drug abuse or dependency. Although the drug abuse treatment community has attempted to adapt many of these therapies to meet the needs of drug dependent clients, but more still needs to be accomplished in the development of new and modification of already established therapies.
The Framework l
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As a result of the lack of a comprehensive approach for the assessment, diagnosis, treatment and after care for substance related disorders, a method needed to be developed to satisfy the needs of both the client and the clinician. Therefore, Ideally this approach should: Serve the needs of the individual with a substance related disorders. Provide the clinician with a therapeutic approach that is easy to remember and administer. Allow the clinician to apply this method within a Biopsychosocial framework.
The Framework l
The DECLARE Model was conceived, with the goal of developing a method of therapy that was designed specifically for the situations and needs of drug and alcohol abuse victims based on seven biopsychosocial stages.
DECLARE l
Thus, the present model was founded on the notion that an admission or (declaration) by the client, at some level of self-conscious awareness, that he/she is abusing drugs or is chemically dependent or at least has a problem .
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Making this declaration is an essential step before effective intervention can be initiated.
DECLARE Model: The Framework l
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The disease of chemical dependency involves an interaction of three constituent systems: (1) biological (2) emotional/motivational (3) social To understand these systems, an “ideal� assessment, diagnostic, treatment and after care methods should include the following: Admission by the client that he/she is dependent or has a problem with alcohol or drugs--again an essential step before effective intervention can begin. A schema that is easy to remember and to administer. Have clear and effective treatment strategies.
DECLARE Model: Definition of Chemical Dependency Definition Chemical dependency is a primary, often chronically learned set of negative behaviors that are characterized by continuous or episodic impaired control over drug use. There is compulsion to use the drug despite the negative consequences. Distortions in the cognitive, emotional, and behavioral spheres occur, resulting, most notably, in denial, diminished selfesteem, confusion, and loss of significant resources.
Course Chemical dependency is a complex set of interactions between biological, psychological, and social factors over time. Those who demonstrate a vulnerability to develop chemical abuse and dependency may potentially become chemically dependent.
Treatment Multifaceted in approach, treatment is determined individually according to the causal and maintaining factors revealed in the client’s Stage Profile.
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The model is an approach utilizing methods for assessment, diagnosing, treating and after care for chemical misuse, abuse and dependency based on seven biopsychosocial stages, or points of entry.
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The model has some aspects in common with other approaches such as: Social Learning Theory, Motivational Interviewing, Stages of Change, Person Centered Therapy, Multimodal Therapy, and Positive Psychology.
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The DECLARE model utilizes a unique approach that fits the treatment to the client rather than the client to the treatment.
D.E.C.L.A.R.E. STAGES l l l
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The Seven Stages of the DECLARE Model are: Denial The substance abuser refuses to believe or allow conscious awareness of the threatening or unpleasant aspects of drug abuse. Esteem Issues arise concerning feelings of personal selfworth. Self-worth can be defined as a basic psychological feeling that all human beings possess in varying degrees. This feeling is compromised or absent completely among those who abuse drugs.
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Confusion The drug abuser begins to recognize the effects of having little or no regularity or predictability concerning normal life experiences. The lifestyle of the drug abuser is now chaotic, unmanageable, disorganized, and controlled by the demands of the drugs. Loss of Significant Resources The user develops overt awareness of the problems that begins to occur as the result of the loss of the drug abuser’s most important possessions. examples: health, family, friends, job, finances, legal status, etc.
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The first four stages of the model Denial, Esteem, Confusion and Loss of Significant Resources represent the assessment and diagnostic phases of the model.
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The model utilizes five instruments to evaluate an individual’s use, abuse and dependency. These instruments are:
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DECLARE Drug and Alcohol Screening Questions which is used to screen for drug and alcohol problems and/or issues. This instrument is also used to facilitate the management of issues regarding the client’s Denial .
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The Taylor Drug and Alcohol Historical Questionnaire is used to assess and diagnosis drug and alcohol disorders.
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Multifaceted Assessment of Chemical Dependency Inventory II is used to develop a Stage Profile and treatment plan.
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Biphasic Analysis Reintegration Sequence Forms II is used to assist in relapse and after-care management.
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Taylor Draw A Person in the Rain is used to assess the client's level of state anxiety. (due to time will not be discussed).
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Acceptance Drug abuser now finally accepts his/her dependency on drugs by saying “I want to stop hurting, “I need help,” “I want/need to change.” This acceptance signals the beginning of the search for treatment and eventual recovery. Resolution Individual seeks a course of action. The form of resolution takes varies from person to person. The stages of Acceptance and Resolution of the model represent the treatment phase..
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Entry Client has now achieved disengagement from the world of drug abuse and is in the process of entering/reentering conventional society where drug abuse has no place. Entry/reentry process follows the Biphasic Analysis Reintegration Sequence (BARS) process.
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The Entry stage has two phases: Phase 1 During this initial phase the abuser demonstrates disengagement from the world of drug abuse.
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Phase 2 In this phase the client continues maintenance of therapeutic gains through appropriate aftercare. During this phase the client is unwilling to jeopardize those gains and refuses to continue participation in self abusive drug behavior.
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The Entry Stage of the model represents the recovery and after-care phase of therapy. The client is ready for Entry when he or she has achieved full disengagement (at least 90 days of complete abstinence) from the world of drug abuse and is entering/reentering conventional society, where drug abuse has no proper place.
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The major focus of this stage is to assist the client in: (a) avoiding some of the most common, often predictable, social/psychological hemorrhaging factors producing relapse and (b) developing a reasonably comfortable and satisfactory lifestyle enhanced by a sense of freedom from the downward spiral of drug abuse.
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In part the Entry stage involves the assessment of the person’s readiness to return to the world he or she left, and part of the returning to this “real world” involves the recognition and awareness that this world is full of challenges, some of which participated in the individual’s abuse.
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Some of the challenges may involve subtle biopsychosocial factors such as cravings, resentment, comorbidity, anger, poor social relations, mood changes, lack of meaningful support a dearth of sobriety and maintaining leisure time activities.
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By putting adequate emphasis on aftercare and recovery (Entry), clinicians can reduce recidivism and enhance rehabilitation, enabling the client to return to a community that is supportive of growth and accomplishment, rather than to an environment that perpetuates problem behavior.
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In the Entry stage the clinician advocates exploring new avenues designed to move the client to maintain sustained change.
Pre-treatment/Post Treatment l
The concepts of the model work within both a pretreatment and post treatment context.
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According to this schema, pre-treatment places greater emphasis on the biopsychosocial assessment and diagnostic processes and less upon the Entry process.
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In the post-treatment, this dynamic is reversed, that is, greater emphasis is placed on the Entry/Aftercare, i.e., the psychosocial process and less on the assessment and diagnostic processes.
DECLADINE: Pre/Post Treatment Dynamics
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Thus, the model is a comprehensive and flexible treatment methodology that would allow for intervention on seven levels, offer specific procedures for compiling information, and provide clinicians with a schema that is easy to remember and simple to administer within a biopsychosocial framework.
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The DECLARE Model meets the needs of individuals with substance related disorders and those with co-occurring emotional and behavioral problems. The model provides the clinician with a therapeutic approach that permits the clinician to use this method with his or her own flexible approach within a biopsychosocial framework.
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Comparing the DECLARE Model to Other Models
The model shares some similar characteristics with Motivational Enhancement Therapy and the Stages of Change Model. The following is a description of the similarities between the other two models. The DECLARE Model counseling techniques are similar to those of Motivational Enhancement Therapy such as eliciting self-motivational statements, listening with empathy, questioning, feedback on assessment results, affirming the client by a positive working relationship, self responsibility, personal empowerment, free choice and handing resistance, (i.e., issues of denial).
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In the Stage of Change Model people who are not considering change in their problem behavior are described as Precontemplators. In the DECLARE Model they are described as being in Denial. The second stage of the model Contemplation entails individuals beginning to consider both that they have a problem and the feasibility and the cost of changing that behavior. In the DECLARE Model it is described as diminished Esteem, Confusion, and Loss of Significant Resources Stages.
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In the Change Model as individuals’ progress, they move on to the stage of Determination, where the decision is made to take action and change. This stage is analogous in the Declare Model as Acceptance. In the Stages of Change Model once the individual begin to modify his/her problem behavior they enter the Action Stage. The Action Stage of the Stages of Change Model is compatible to the Resolution Stage in the DECLARE Model.
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Finally, after successfully negotiating the Action Stage of the Stages of Change Model, individuals move to the final stage of Maintenance or sustained change. In the DECLARE Model this stage is represented as the Entry Stage or where the client has achieved disengagement from the world of drugs. The client now is unwilling to jeopardize gains received in therapy
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(next slide).
D.E.C.L.A.R.E. MODEL
STAGES OF CHANGE
Denial Stage The individual refuses to believe or allow awareness that a problem exists and does not consider change in the foreseeable future.
Pre-Contemplation Stage The individual is not seriously considering modifying the addictive behavior in the foreseeable future
Esteem Stage ; Confusion Stage; and Loss of Significant Resources Stage The individual experiences diminished self-esteem as a result of the drug and experiences confusion in his/her life; begins to experience significant losses and realizes that he/she needs to consider change.
Contemplation Stage I want to change, But then I don’t. Ambivalent about the change process rather unmotivated or in “denial”.
Acceptance Stage Abuser accepts his problem by saying” I want to stop hurting” I need to change
Preparation Stage Making and strengthing a commitment to change in the face of difficulties, managing temptation and slips that provoke relapse.
Resolution Stage Client begins to seek a course of action, i.e., drug treatment thereby making a commitment to change in the face of difficulties, managing temptation and slips that provoke relapse.
Action Stage The individual begins to break the physiological, psychological, and social ties that bind him/her to the addictive behavior. They separate themselves from the old patterns and begin to create new ones.
Entry Stage The client has achieved disengagement from the world of drug abuse and is now entering/reentering conventional society, in which drug abuse has no place. The entry/reentry process follows the Biphasic Analysis Reintegration Sequence (BARS): Phase 1 Demonstrate disengagement from the world of drug abuse. Phase II Maintenance of therapeutic gains through appropriate aftercare, which the client is unwilling to jeopardize by again becoming involved in drug abusing behavior
Maintenance Stage The client does not engage in addictive behavior which now becomes the personal norm. The client now counters threats and temptations by checking and renewing commitment and making sure that the decisional balance remains negative for reengaging in addictive behavior. The client establishes a protective and satisfying lifestyle
DECLARE Model of Chemical Dependency l
The DECLARE model represents a nonlinear, multifaceted, cognitive-behavioral, proactive approach that may answer the challenges of chemical dependency.
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DECLARE Model can be an effective way to answer the challenge of chemical dependency. It presents a results oriented approach to the assessment, diagnosis, treatment and after-care of substance related disorders based on a three-part commitment:
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The Model Contains The Following Three Components
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A paradigm for conceptualizing substancerelated disorders
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A treatment procedure
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A method for the pursuit of scientific inquiry into the etiology, diagnosis, treatment, disengagement, reintegration, and aftercare of persons with substance related disorders.
Within the three-part model of the DECLARE approach is a biopsychosocial paradigm of substance-related disorders that is based on three perspectives which can be subdivided into various components. The first perspective is micropsychological. Theory
Micropsychological
Biopsychological
Intrapersonal
Neuronal & Structural (hardware)
Information processing (software)
Micropsychological Perspective: Neuronal Effects l
This perspective emphasizes the biological effects of drugs on the brain.
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All the biochemical actions that take place in and between the neurons are responsible for all our thoughts, actions, memory and behavior. Drugs that affect these processes are referred to as psychoactive. In effect these psychoactive drugs are chemicals that alter, potentate, mimic, disrupt or inhibit the normal neuronal processes associated with normal function or communication within the brain. Therefore, to comprehend the action of psychoactive drugs it requires some knowledge of the neurons and how neurons interact with each other.
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The human brain when healthy is much like a fine symphony orchestra which plays beautiful music ,i.e., our thoughts, feelings and behaviors. Like an orchestra if the instruments (hardware-structures) are not tuned and the wrong sheet music (software-neurotransmitters) is played the music is horrible.
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This is similar to what happens in the brain when its structures receive the wrong sheet music, i.e., psychoactive drugs
Micropsychological Perspective: Neuronal Effects
The DECLARE Theory OF Chemical Dependency: An individual experiences addiction whenever a set of specific neural “gates� open regarding the substance used. This in turn causes an initiation of a motor and autonomic dysfunction within the neuropathways and this provides an avenue producing the cycle of addiction.
Points of Addiction l l
Addiction is seen as an experience that shares properties of chronic pain. During any point of the development of addiction, the abuser moves into a state referred to as the Valley of Tears Syndrome (VTS). l l
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VTS is the biopsychosocial dimension of despair, loss of personal dignity, isolation and loneliness. No victim can return from this state without intervention.
During this path of self-destruction, euphoria leads to dysphoria, causing more frequent use of the substance to restore the diminishing euphoria. Eventually, the dysphoric stage becomes the dominant phase.
Micropsychological Perspective: Structural Effects l
When structures of the brain (i.e., cerebral cortex) are altered by drugs, neuropsychological anomalies are produced, resulting in behavioral alterations (i.e., mood changes).
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When substance abuse reaches this stage, the abuser is not making a cognitive choice to ingest the substances; the user-turned-abuser now needs the substance, even if it means to engage in antisocial and/or criminal behavior to obtain the drug.
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Keep in mind that once the individual reaches this stage of abuse, the addiction is not for the drug but for the feelings produced by it.
Use, Abuse and Vulnerability l 1.
The tendency to use and abuse drugs is related to these vulnerability factors: Vulnerability to use one of the mood-altering substances (e.g., availability of the drug)
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Vulnerability to use a drug for other than medicinal purposes (e.g., abuse that results in the impaired physical, social, mental, and emotional well-being of the user)
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Vulnerability to develop the disease because of physical, genetic, psychological and social factors.
Next slide shows this relationship
Valley of Tears l
Represents the relationship among use, abuse and vulnerability.
Addiction only occurs when all three overlap (VTS)
The second perspective of the DECLARE Model is the biopsychosocial paradigm referred to as the Macropsychosocial /Cultural Perspective
Macropsychosocial/Cultural
Nonwestern society Dynamic Tension
Entopsychic processes
Declatypes
NBO
PBO
Postindustrial society
Macropsychosocial Perspective l
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Offers the concept that there are disturbances within the personality that assist in maintaining substance abusing behavior (entopsychic) leads to certain patterns of behavior (declatypes) associated with faulty cognition skills. To stop these dysfunctional patterns of thinking and behaving, the abuser must reestablish entopsychic equilibrium and develop a new set of coping skills in society.
Macropsychosocial Perspective: Negative Declatypes l
This perspective emphasizes that disturbances of psychic forces within the personality that maintain substance abusing behavior (entopsychic) gives rise to certain patterns of behavior (declatypes) that are associated with dysfunctions in thinking and behaving. l
more specifically, they refer to negative behaviors displayed by those abusing despite adverse consequences and can be grouped according to four basic stages: Denial, Esteem, Confusion, and Loss of Significant Resources.
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The Model considers these predictable negative patterns to be universal.
Negative Declatypical Syndromes l
These syndromes are apparent to everyone but the abuser. l
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the abuser is so strongly preoccupied with drug-abusing behavior that he or she is incapable of thinking about anything other than getting high.
Every addict’s negative declatype(s) acts as an infrastructure associated with relevant experiences that construct a syndrome. l l
the syndrome gains in strength due to the accumulation of new experiences that are associated with one of the declatypes. the syndrome eventually controls the abusers thoughts and actions in an extreme and unlimited capacity. The result is uncontrolled self destructive drug taking behavior despite any negative consequences.
Acquired Negative Declatypes l
Because of conditions such as Fetal Alcohol Syndrome (FAS) or Fetal Drug Syndrome (FDS), an abuser may have been predisposed to abusing drugs because of the experienced secondary to drug use.
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In the DECLARE Model, these acquired patterns of behavior (acquired declatypes) are reservoirs of biopsychosocial symptom clusters. l the development of these clusters is due to interferences with the growth process during the prenatal period
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If a mother uses or abuses drugs during the developmental stage of the fetus, the baby will inherit addiction and experience withdrawal when he/she is born.
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Also, if a mother uses or abuses drugs when pregnant, she risks damaging vital tissue leading to the potential death of the fetus.
Entopsychic Processes l
One of the major challenges in assisting an abuser is understanding his/hers entopsychic processes, or their adoption of inappropriate patterns to cope with needs and problems, that have resulted in the abusive path. l the therapist must understand the client’s Declatypes and how it produces and affects certain behavior patterns and personality functioning.
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The typical addict conceals his or her problems so the therapist must view the addict from the perspective of how and why these concealments take place.
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The therapist must reveal and uncover the entopsychic processes of the client in order for them to relearn social/emotional skills to live a healthy life.
Fitting Treatment to the Client l
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The DECLARE Model employs two basic orientations, one Negative and one Positive, which enables the treatment to fit the client rather than the client to the treatment l
Negative Behavioral Orientation (NBO) refers to the behavior characterized by thoughts and feelings related to failure, frustration and fears that lead to chemical abuse/dependency despite its consequences.
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Positive Behavioral Orientation (PBO) refers to the development of self-control on the part of the client, to be aware of the extent or his/her abuse.
Eliminating the NBO is the Main Target of the DECLARE Model A PBO encourages the client to direct his or her actions toward achieving some specific set of goals without drugs which will lead to the pursuit of opportunities that make his or her hopes and dreams concrete realities.
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In the DECLARE Model, the dynamic process of positive and negative behavioral orientation is graphically depicted by the Behavioral Orientation Configuration Model (BOC)
The BOC Model
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the BOC Model depicts the decision on the part of the individual to use a drug or drugs and then move on to drug abuse, after passing through a zone of sensitivity (to the drug). At this point the individual is set for a substance-related disorder. Once at the junction (i.e., at the bottom of the "V�) the drug abuser must then decide or make a declaration to stop or continue his or her journey. l
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The abuser decides to proceed to the right toward a PBO, then he/she will not develop a substance related disorder and can enter society as a chemically free individual.
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Should the abuser decide to go toward an NBO, then he/she moves into the critical period zone, where the risk of developing the substance related disorder increases.
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From this junction, the drug abuser moves into the trauma of pain and loneliness referred to a as the Valley of Tears Syndrome and develops a substance related disorder.
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The establishment of an individual's behavioral orientation is crucial to the success with the DECLARE Model for it is only after a PBO or NBO is determined that an efficient and potentially effective plan for treatment can be initiated.
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In effect, it is the NBO and PBO that provide a focus for treatment, helping the client to develop an awareness of how much of a problem their use of drugs poses for them and how their use has effected them (both positively and negatively).
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Thus, tipping the balance towards change (i.e., PBO in place of a NBO) is essential for movement from Denial to Entry. Therefore, assisting the client in tipping the balance towards change is an important part of the process in monitoring and responding to the client during the feedback phase of treatment. (next slide)
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The client determines their own behavioral orientation by making a declaration to use or not to use.
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Creating Change: Decisional Balance
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The DECLARE Model attempts to shift the decisional balance in favor of the PBO.
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Building motivation for change by giving up their NBO and strengthing change by embracing a PBO. Clients will of course vary in their readiness to relinquish their NBO.
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On the one hand some may come to treatment determine to change. On the other hand there will be others who will be reluctant or even hostile at the outset.
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The NBO is one side of this seesaw or the status quo (i.e., continue abusive drug taking behaviors), whereas the PBO favors change. The former (NBO) side of the decisional balance is weighted down by perceived positive benefits from abuse and feared consequences of change.
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The other side (PBO) consist of perceived benefits of changing one’s abuse and feared consequences of continuing unchanged.
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The task of the DECLARE Model is to shift the balance in favor of the PBO, or change. Next slide
Creating Change :DECLARE Ambivalence Model
PBO
NBO
CON’s
PRO’s
PRO’s
CON’s
Decisional Balance Decisional Balance
No Change
Change Behavior
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Once the orientation has been established, the abuser may be counseled about behaviors that may appear during treatment and that could potentially prevent positive growth and emotional stability—that prevent a movement toward empowerment.
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When a client is made aware that others in therapy have experienced these potential roadblocks to recovery, he/she may be better able to cope if and when such behaviors begin to appear.
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Adequately warned, the client is in a better position to avoid the feelings of inadequacy, inferiority and/ or isolation that frequently occur; and to continue on the road to recovery.
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One of the basic, and most crucial, goals of drug treatment is to assist the client through his or her journey to wholeness.
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To become a fully functioning, well-integrated person, an individual must know himself or herself as completely as possible.
Understanding the Client l
The clinician must also encourage and foster in the client a PBO based on self-awareness of his or her drug-abusing behavior. This initiates a three-fold process of positive declatypes: Abuser accepts reality of abuse/dependency upon drugs (declatype of Acceptance) Seek treatment (declatype of Resolution)
Return to society drug free (declatype of Entry) l l
The abuser can choose whether to proceed to a PBO or a NBO. An understanding of this will provide a focus for therapyonly after that can an effective plan of treatment be initiated.
The next Perspective in the DECLARE Model’s biopsychosocial paradigm is the Metapsychological Perspective. Metapsychological
Transcendental
Churchill syndrome
Metapsychological Perspective l
Many abusers in recovery show greater levels of faith and spirituality than those continuing to relapse.
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Spirituality embraces the sides of darkness and light-the experience of being lost and of being found.
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The abuser experiencing this spirituality is moving out of the Valley of Tears (VTS)- a state of psychological pain, isolation, depression, anxiety and loneliness- to a liberating and exhilarating state of becoming free. l this journey is referred to in the model as a transcendental experience.
Metapsychological Perspective: The Churchill Syndrome l
The DECLARE Model embraces this sense of spirituality and calls it the Churchill Syndrome (after Winston Churchill)
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The letter� V “ is used to demonstrate the relationship of the Churchill Syndrome to the seven basic DECLARE Stages and Victory over the ravages of dependency.
The next Perspective in the DECLARE Model is the biopsychosocial paradigm
Treatment
Multifaceted Treatment Acceptance, Resolution
Enter After-Care Biphasic Analysis Reintegration Sequence
Phase 1
Phase 2
Multifaceted Approach l
For intervention for chemical dependency to be effective, the involvement of the three constituent systems- biological, emotional/motivational and social- must be taken into account.
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It is important for the clinician/therapist to keep in mind that drug abusers represent a wide diversity of individuals. l If we are to expect any measure of success, it is necessary to develop a treatment approach that understands and responds to this diversity.
Multifaceted Approach l
The strength of the DECLARE Model lies in its multifaceted approach that aids the therapist in identifying needs related to: l l l l l l l l l l l
Psychological profile Physiological makeup Social environment Cultural background Gender-specific concerns Counseling services Individual and group treatments Use of chemotherapeutic agents in treatment Daycare Birth control Other
Medical Psychotherapy in the DECLARE Model l
The DECLARE Model relies heavily on the definition proposed by Pruzensky (1988) concerning medical psychotherapy, a hybrid discipline composed of many subdisciplines, including: l l l l l l l
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Consultation-liaison psychiatry Clinical psychiatry Nursing Pediatric psychology Medical psychology Health psychology and counseling Behavioral Health
The DECLARE Model combines a medical psychotherapists knowledge of personality functioning and change combined with cognitive behavioral practices, producing prevention, rehabilitation, and provision of direct services.
The final Perspective in the DECLARE Model is the biopsychosocial paradigm
Research l
Research
Prevention
Program Evaluation
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An article on the model was submitted to The Journal of Mental Health Counseling in June of this year. Research that is currently being conducted utilizing the model are: The DECLARE SCREENING INSTRUMENTS – reliability studies using the CAGE, AUDIT and the T-ACE using the DSM IV and the ICD 10 as the diagnostic “Gold Standards”.
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Research using the TADHQ and the DSM-IV for diagnostic prediction.
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The use of the model in both clinical and non-clinical settings
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The models effectiveness in assessing and treating minorities, youth and women.
Recent Completed Research Using The DDASI N=715 Undergraduate Students l
An internal consistency estimate of reliability was computed for the DECLARE and the CAGE screening instruments. The seven item DECLARE measure had a Cronback's alpha of .690 with a 95% confidence interval, lower bound of .645 and an upper of .731 which was statistically significant. The four item CAGE measure has a Cronbach's alpha of .626 with a 95%confidence interval lower bound of .568 and an upper bound of .678 which was also statistically significant.
Research utilizing the DECLARE, CAGE and the AUDIT is being proposed now in a variety of clinical settings using the DSM IV-TR “as the gold� standard to test the diagnostic value of the DECLARE screening instrument in the evaluation of clients with drug and alcohol abuse or dependency problems.
Other Uses of The DECLARE Model l
It may also be used in treating children, adolescents, adults, co-occurring disorders, couples, families, and/or groups
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The model represents a comprehensive approach that can be applied to a variety of other problem situations. This perspective can be described as a transtheoretical model because it may be applied to a number of other situations. Sexual perpetrators
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Romantic Relationships Victims of sexual abuse Battered women Perpetrators of abuse Grief victims Clients dealing with co-dependency and other relationship problems Individuals suffering from addictions of many types (e.g., food, gambling, etc.)
DECLARE’S Multifaceted Approach l
DECLARE Model uses the following five instruments in the assessment, diagnosis, treatment and after care of those with substance abuse issues:
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DECLARE Drug and Alcohol Screening Instrument
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A structured interview the Taylor Drug and Alcohol Historical Questionnaire-II
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Multifaceted Assessment of Chemical Dependency InventoryRevised (MAC-D-R)
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Biphasic Analysis Reintegration Sequence (BARS)
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The Taylor Draw-A-Person-In-The-Rain Anxiety Scale Revised (DAPIR-R) (optional)
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Other Instruments There are other instruments which may be used in the assessment process but are not required. Clinicians may want to supplement instruments not listed below that they deem appropriate for there specific situation. Neuropsychological screening tests Paper/pencil tests (DAP) MMPI-2, MMPI-A Mac Andrew Scale Beck Depression Scales Wechsler Adult Intelligence Scale-R
How to use the DECLARE Model Drug and Alcohol Screening Detoxification Assessment Diagnosis Treatment Plan After-Care
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Drug and Alcohol Screening
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The DECLARE Drug & Alcohol Screening Questionnaire is used for determining the need for treatment and the management of denial.
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DECLARE Drug and Alcohol Screening Questions and there use in the management of Denial
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To assist in the assessment, diagnosis and treatment of substance abuse various psychometric instruments have been employed. These instruments assist in selecting appropriate measures that enhance the clinicians understanding of the exact nature, dynamics, severity and affect of the client’s substance abuse.
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Along with the DECLARE Drug and Alcohol Screening Questionnaire other assessment devices such as the Michigan Alcohol Screening Test , T-ACE Question , and the CAGE Questionnaire have been used by clinicians to obtain a general overview of the client’s alcohol/drug usage.
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DECLARE DRUG & ALCOHOL AS A SCREENING INSTRUMENT
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In the use of the screening instrument clients are urged to answer as honestly as possible seven questions which are based on the letters of the DECLARE acronym.
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A "yes" answer to two or more of these screening questions is indicative of a drug and/or alcohol problem and the respondent should be asked to complete a drug and alcohol assessment.
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The DECLARE Drug & Alcohol Screening Questionnaire in the management of denial.
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Unless the substance abuser is willing to take an honest and detailed look at what the mood-altering chemicals have done, there is no opportunity to clearly see the magnitude of the problem and unless the client grasps the negative effects of his/her abusing behavior has had, it is unlikely he/she will feel the need to change their behavior patterns.
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In helping the client to acknowledge his/her powerlessness and to break the cycle of denial, it is important that the clinician encourage the client to be honest with themselves.
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It is important for the client to declare his/her powerlessness over chemicals because the foundation upon which recovery is built depends on the acknowledgment of this fact.
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DECLARE Model: Managing the Issue of Denial
In administering the questions encourage the client to respond in writing and give examples, even though it might be uncomfortable to do so. In declaring answers on paper, the client may be more likely to realize that a problem truly exists.
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Only when the client declares that there is, indeed, a problem can he or she begin to do something about it.
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Providing examples by the client to the screening questions is a technique for managing denial and should be conducted as early as possible in the process of evaluation. This may be particularly true if a family member or friend is present during this phase of the interview. Whenever, possible, you should have your client respond to these questions with corroboration by a family member or friend.
Managing the Issue of Denial
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After reviewing the examples provided for each question the therapist should point out to the client the problems and difficulties presented.
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Scenario: Mr. Smith you have answered yes to three of the questions on the questionnaire. Mr. Smith you indicated the you have driven an automobile while under the influence of alcohol and was involved in an accident. You also indicated you have been arrested for fighting while under the influence of alcohol and as a result lost your wife and job. In addition you indicated that you feel remorseful about all the problems you caused your mom and dad because of your drinking.
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The therapist at this point would say, Mr. Smith it would seen to me that based on your responses that a reasonable person would conclude that you have a problem with your drinking behavior and I am wondering what you think about this now?
l Detoxification, Assessment
Diagnosis
and
Detoxification l
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The DECLARE Model is an appropriate and effective treatment approach for both an outpatient and inpatient setting, using a triphasic process of detoxification. In an impatient setting: The first phase is complete abstinence from all types of psychoactive drugs, except drugs prescribed by a physician. l
During this phase biological/medical intervention may be required.
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In this phase the client is also informed about the physical symptoms encountered during the detoxification process.
The second phase addresses the physiological, physiotherapeutic, and recreational treatment needs of the client which includes: l l l l
A balanced diet at fixed intervals (three times a day) Food supplements Exercise consisting of walking, jogging Massages to dissipate muscular cramping
Detoxification (cont.) l
The third phase emphasizes the client’s need for psychological and emotional support.
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After completion, the client is introduced to the DECLARE approach to treatment.
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Issues and problems in the Stage Profile ( discussed later) should be identified in concrete cognitive and behavioral terms and there urgency and priority explained. l
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Global complaints should be made specific by breaking them down into their component parts, to prevent them from becoming overwhelming. To achieve this, there is a number of techniques that can be useful in assisting the client to achieve victory over chemical dependency.
Assessment-Taylor Drug and Alcohol Historical Questionnaire-II l
Taylor Drug and Alcohol Historical Questionnaire-II l This is a structured interview questionnaire designed to assess the client’s alcohol and substance abuse history by using the DECLARE acronym. l The
clinician should use this instrument as part of a structure interview by asking questions directly from the questionnaire.
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After completing the interview the clinician should review the questionnaire and clear up any misconceptions prior to developing an initial Stage Profile and treatment plan.
Assessment-TADHQ l
The following information is gathered from the client regarding his or her current situation with drugs or alcohol utilizing the TDAHQ. Medical and psychiatric histories l l l l l l l l l l
The seven Stages of the Model Family demographics and history Legal History Current living situation Recreational preferences Precipitating events Circumstances of drug abuse onset Specific characteristics of substance abuse Psychological and physiological complaints Mental Status Examination
Making the Diagnosis l
After the collection of information from the various areas on the TDAHQ the clinician will now begins the process of reviewing and evaluating information from both the first four stages of the model i.e., Denial, Esteem, Confusion and Loss of Significant Resources and the mental status examination.
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The clinician then makes a diagnosis based on the information found in the TDAHQ using criteria from the DSM 窶的V-TR or the ICD regarding abuse or dependency.
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This information will be used to determine which stage(s) should be the focus of treatment using the MAC-D instrument.
The DECLARE Model is a Multifaceted Approach l
Drug abusers represent a wide diversity of individuals from many diverse backgrounds and groups, such as gender, sexual orientation, age, race, drug(s) of choice, amount used, how taken and cultural background.
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The model identifies those needs which are representative of the specific group to be addressed.
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The use of this multifaceted approach demands therapeutic techniques and strategies which are flexibility, timely and sensitive. These strategies also incorporate directing the client towards motivational change, feedback where appropriate, empathic reflection, creating and amplifying discrepancy to enhance motivation for change, resist labeling, problem solving and clinical intuition.
Goals of the DECLARE Model l
In the DECLARE Model the assumption is that the responsibility and capability to change lies within the client, i.e., the client must DECLARE and give up their NBO.
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This models is similar to Motivational Enhancement Therapy .
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The goals are:
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Evaluate the stages in the model Establish Rapport Assess and evaluate the presenting complaint Develop discrepancy (managing denial with pro and cons ) Avoid argumentation Express empathy Handle resistance Support self-efficacy Determine the best course of treatment
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DECLARE Model's Personal Socialization Process l
With the initial contact, the client becomes socialized to the model's fundamentals of self-management through the effective utilization of coping mechanisms.
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The therapist informs the client that substance-related disorders are experienced in stages. l
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To the client, the management of substance-related disorders is presented as a set of skills. l
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This approach emphasizes the many windows of entry for coping with substance abuse.
The client is informed that as strengths in one stage increase, they may compensate for weakness in others.
The Stage Profile traces the client’s progress and the therapist noting each small success in resolving specific problems within a given stage which will alter the total picture for the chemically dependent individual.
The Models Personal Socialization Process l
The clinician and client engage in a honest discussion of the individual’s drug use as a complex, multifaceted phenomenon.
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The clinician emphasizes that there are many windows of entry for coping with substance abuse and changing a NBO to a PBO for ameliorating addiction.
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The key to success is for the therapist to provide a consistent message throughout the process that he/she is responsible for their behavior and they have the freedom of choice to recover from their self abusive use of AOD. The therapist needs to understand what stage the client is in and to assist him/her in developing discrepancy so appropriate intervention can begin. Also, to move the client towards a firm decision to maintain a PBO or positive change.
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Understanding the Concept of The Stage Profile
The Stage Profile l
Its purpose it to determine what stage(s) of change the client presents in their abuse/addiction cycle and to assist him/her to move through the stages toward successful sustained change.
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Knowledge of the stage(s) where the client is in his/her abuse cycle will aid the clinician in directing the focus of therapy.
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In completing the stage profile, the clinician must remember that a client may progress from one stage to the next and conversely, may move backward to a previous stage.
Multifaceted Assessment of Chemical Dependency InventoryRevised l
In the DECLARE Model the MAC-D-R is the clinicians guide for use in devising multifaceted approaches to problems solving in treatment planning with of those displaying substance-related disorders. l
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The inventory facilitates information gathered from a thorough assessment across all seven DECLARE Stages taken from the TDAHQ. This will provides the clinician with a diagram for processing and evaluating data provided by the client.
The profile facilitates the adaptation and fitting of psychotherapy to the client’s unique needs. l Therapeutic interventions are organized to target specific problems listed under individual stages.
Stage Profile Multifaceted Assessment of Chemical Dependency II This instrument is designed for used in the development of a stage profile of the individual use and abuse patterns in each of the seven stages of the model.
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The instrument allows the clinician to analyze each of the DECLARE Stages to determine which stage(s) should be addressed for treatment.
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The instrument includes a Stage Severity Worksheet which allows the clinician to both provide a risk rating for each stage (a risk rating of 3 or more for any Stage must be included in the treatment plan) and a confidence rating of the client’s truthfulness in the information provided.
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The instrument also allows an optional section of incomplete statements for the client to respond to (projective).
Stage Profile l
The stage profile is to be conducted within the first two sessions after completing the TDAHQ.
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The stage profile is used for listing and systematically organizing the problems and issues to be targeted within the seven biopsychosocial stages ( found in the MAC-D form) for intervention and later development of a treatment plan.
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Individual stages are not mutually exclusive, although the categories are distinct conceptually and problems are sometimes listed under more than one stage.
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The ideal path is direct from one stage to the next until continued disengagement from the world of drug abuse has been achieved. Most clients with serious problems with drugs or alcohol, however, will slip or relapse and fail to Enter or re-entry society drug free. Those who relapse may go through the stages several times before they learn how to change successfully.
Stage Profile (Cont.) Procedural Questions l
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There are a set of specific questions used in the Stage Profile that have been found to be helpful in building the client’s stage profile. The questions that follow provide information related to the clinician, client and their expectations regarding use and abuse, goals, self-worth, daily life, future, health, and personal and social values.
Stage Profile (Cont.) l
Some Procedural Questions: Ø Ø Ø Ø Ø Ø
What are the client’s personal constructs as to why the abuse is taking place? How has the client coped with substance-abusing behavior and how has it affected his/her daily life? What level of commitment is the client willing to work on to change negative behaviors? What are the clients expectations of life after abusing has stopped? Does the client believe he/she can change? Is change worth it?
Development of the Stage Profile
and Treatment Plan
Questions l
In the development of the Stage Profile there are two basic questions the clinician must ask of the client:
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How hard are you willing to work on changing your negative behavior (s)? What expectations do you have concerning how your life will be different after your substance-abusing behavior has been arrested?
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Completion of the Stage Profile * Must return to the TDAHQ stage sections to get needed information on each stage for the profile.
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DECLARE MODEL’S STAGES Denial Esteem Confusion Loss of Significant Resources Acceptance Resolution Entry
The Stage Profile l After review of the responses from the TDAHQ, the clinician will then transfer this information to the appropriate six subsections of each of the seven stages in the model on the stage profile form found on the MCD-R Inventory. Each subsection is to be completed according to the definition of the stage being worked on. l
•Special attention must be paid to the client’s level of discrepancy and self-efficacy while completing each subsection.
Stage Profile Esteem Stage Severity Rating_____
Issues arise concerning feelings of personal self-worth. Self-worth can be defined as a basic psychological feeling that all human beings possess in varying degrees. This feeling is compromised or absent completely among those who abuse drugs. Strengths of this stage What is positive? Weaknesses of this stage What is negative? Problems or Issues in this stage Both positive/negative What event (s) led to diminished self esteem What are the consequences of not taking action in this stage What level of action is required to resolve this stage Low, Medium, High
Stage Profile: Treatment Plan l
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After completing each of the subsections for each Stage on the MAC-D Inventory the clinician will then review each Stage and determine if it meets criteria for inclusion in developing a treatment plan. If a Stage is scored 3 or more then it must be included in the client’s treatment plan. The clinician will then develop goals and objectives in consultation with the client reflecting those Stages identified for inclusion. The clinician will suggest strategies to assist the client in meeting his goals and objectives. Clinician may utilize techniques and procedures employed in the model or their own flexible approaches within a biopsychosocial framework.
Stage Profile with the Dual Disordered Client. l
This same procedure is utilized when working with a dual disordered client.
• the exception is that the mental status examination and the suicide/violence portion will play an important role in developing a treatment plan designed to address both the drug abuse/dependency and mental illness issues.
DECLARE MODEL Treatment Techniques l
There are 9 Process and fifteen therapy techniques are taken from them in the DECLARE Model
Treatment Techniques l
Stress Reduction: l
This technique encourages clients to identify the sources of stress in their daily lives, to note the various ways they experience stress and to develop strategies for reducing it
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The following questions and instructions may be used to assist the client in developing a journal or a daily log: l l l l l l
Notice when you need the drug Where are you feeling the discomfort? Describe the discomfort Notice your surroundings. Where are you? Is anyone with you? Who? What’s your first response to the discomfort? What do you want to do? Do you want to take a drug or escape your surroundings? What did you finally do?
Treatment Techniques l
DAPIR Anxiety Scale-Revised (optional) l
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The Taylor Draw-A-Person-In-The-Rain Anxiety Scale-Revised is a method that assesses the level of anxiety being experienced by the client The subject is given an a sheet of paper and asked to “draw a person in the rain� A scoring manual designed by the author to asses the anxiety has been created so the indices many be scored by 1,2,3,4, or 5 A table of norms and T-score values , percentiles, means, standard deviations, reliabilities, and a psychogram are provided to determine the level of state anxiety in the client.
Treatment Techniques l
The Empty Chair Technique: l
The therapist has the client enter into a dialogue with the drug in an empty chair, encouraging the client to role-play both sides of the conscious/unconscious split in personality while sitting in the chairs (which are facing each other) l
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The instructions may sound like something: Your drug is sitting in that chair opposite you. Please sit in that chair now and give your drug a voice. Speak for the drug, to yourself, in the chair you just left
Whenever significant experiences occur in the role of the drug, the client is asked to switch chairs and speak for himself or herself to the drug l
The client is encouraged to continue to alternate roles until some important integrations take place
Treatment Techniques l
Self-Hypnosis: l This is a technique that can be taught to the drug abuser in a skill-based program created to alter perceptions and images that depends on the acquisition and reinforcement of several skills: l Focusing attention l Generating vivid images l Inducing a state of relaxed wakefulness l
The hypnotic techniques are based on repeatedly emphasizing: l The deleterious effects of drugs l The clients ability to control his or her own behavior l The importance of recognizing the emotional needs for the symptoms
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The self-destructive drives should be channeled into recreational activities that involve concentration and balance
Treatment Techniques l
Guided Imagery: l l
This is a technique that puts clients in touch with internal processes outside of their awareness The client is asked to relax and to achieve a desirable state, whereupon mental images become dominant l
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The therapist composes a scene that seems to capture the client’s conflicts, fears, and/or desires for change
The therapist requires that the client project himself/herself into the scene and then describe it aloud l l
The therapist selects something or someone alive in the scene and then directs the client to “get in touch” with this “inner advisor” The therapist has the “advisor” take the drug-abusing behavior away from the client while seeking his or her agreement to do so
Treatment Techniques l
Personal Surgery Technique: l
The clients are to imagine that they are surgeons and are instructed to closely examine themselves in an effort to discover the truth about their thoughts and behaviors
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Clients are asked to “cut deeply” under the surface and to expose the faults, failures, shortcomings, and feelings that are producing the substance-abusing behaviors (negative thoughts, personal style, emotions), that is, the NBO.
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As surgeons are fearless and confident in surgery, addicts and alcoholics must likewise be fearless in uncovering the sources of their disease process
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After the layers have been cut away, the “incision” can be closed and the healing process can begin
Treatment Techniques l
Life Boat Fantasy Technique l
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This technique facilitates the therapist’s endeavor to understand the inner world of the addict and is useful when the rationale of the client for abusing drugs resists analysis and remains obscure While the Life Boat technique should be employed during the first several sessions, it can be effectively used at anytime during therapy
Treatment Techniques l
Thought-Stopping l l
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This is an effective technique for combating obsessive and intrusive thoughts about drugs This technique requires the client to subvocally scream, “Stop!" over and over again
Goal Rehearsal l
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This is a procedure that encourages the client to mentally rehearse a desired behavior and can be considered a form of problem solving in advance This has positive outcomes can increase the individual’s sense of self-efficacy
Treatment Techniques l
Diversion: l
A procedure that diverts the client’s attention away from drugs and toward something positive l
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One effective method is involvement in recreational activities such as walking, jogging, or some other structured exercise program The client may also be instructed to carry three different objects in his or her pocket and to focus attention on identifying them whenever thoughts of drugs enter into consciousness The client also may be encouraged to carry a symbol of something he or she has lost due to drug abuse
Treatment Techniques l
Time Projection: l
The client is asked to sit quietly and to imagine that he or she is somewhere in the future, six months or a year from the present time l
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The client will then predict what life will be like at this point
Drug and Alcohol Education: l l
The client is asked to read books and/or articles to facilitate progress in therapy To ascertain what (if any) impact the material has had on the client and to clarify ambiguities, client and therapist discuss the readings in subsequent therapy sessions
Treatment Techniques l
Self-Esteem Exercise: l
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This is designed to contradict any internalized messages of worthlessness and replace them with positive-self-worth messages and healthy self-esteem The client will write ten positive statements about himself or herself –five concerning personality and five concerning accomplishments-each starting with “I� The client is then instructed to read the list aloud and the therapist gives a positive response The therapist also looks for signs of embarrassment and uncertainty in their statements and encourages the client to repeat the list until he/she sounds convinced that the statements being vocalized are true
Treatment Techniques l
Write Your Drug Story Technique: l l
The client is asked to write a story about his or her use of drugs and/or alcohol While the presentation of their story, he or she is encouraged to identify thoughts and feelings that accompany the various experiences l
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At this point, the clinician asks the client various questions concerning what was written and what was said
Do I Hate You? Technique: l l
The client is asked to write a letter to the disease of chemical dependency, detailing how much he or she hates the disease The client is then asked to read the letter aloud, after which the feelings regarding the hatred of the disease are discussed
DECLARE Model’s Entry Re-Entry and After-Care
Managing Recovery Challenges l
Recovery challenges are the obstacles that prevent the client from maintaining sobriety. l The recovering addict may find it difficult to understand that recovery is a journey that takes time- it is not a quick fix. l Abstinence is not the only criterion for recovery but also completing a series of daily tasks that allow the management of both acute withdrawal and postwithdrawal while also correcting the biopsychosocial damage resulting from years of abuse. l
Self-Monitoring-BARS: This instrument is used to monitor the client’s progress during this phase of the model.
Self-Monitoring-BARS: l
Self-Monitoring-BARS: l
BARS (Biphasic Analysis Reintegration Sequence) is a self-monitoring technique employed during the entry/reentry phase of drug treatment whereby the client monitors daily activities to remain chemically free. The form has three parts. l
The form includes a craving rating scale from 0 to 100 at the top of the form and a list of common triggers at the bottom of each column, and a place within the form for the client to record their responses for each day of the week. The client is asked to keep track of their daily cravings ratings, thoughts, feelings and triggers that they experience and the actions taken regarding challenges experienced and record them in the large spaces provided on the form.
Self-Monitoring-BARS: l On
part 2 the client is asked on a daily bases to keep track of how they rated the activities of the day/week on a scale of 1 to 10, with1 representing poor, 5 moderate and 10 optimal. Clients may at the end of the day/week record their average craving on the form.
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On part three the client is asked to take a few minutes daily, at bedtime, to select five (non-drug-related) activities (reinforcement menu) that gives them pleasure to enjoy the activities of the next day.
Recovery Challenges l
Recovery challenges include but are not limited to: l l l l l
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Unexpected changes resulting from sobriety Decreased motivation Drinking/drugging when feeling various emotions Slips/ Lapes and Relapses Absence of support from family, friends, and business associates
The recovering addict also needs to bear in mind that these challenges vary and that what appears as a challenge in one situation may not necessarily be a challenge in another.
Challenges of Recovering l
In addressing the challenges of successful recovery the DECLARE Model presents a seven-step program (based on the acronym) that encourages the client to: D. Decide if he/she wants to recover E. Establish a challenge checklist C. Choose what works for the individual L. Lose the fear of recovery A. Act upon the plan that has been established R. Record results E. Evaluate results
Entry-After-Care Seven-Step DECLARE Program l
Decide l l l l
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To avoid being overwhelmed, clients need to focus all their energy on one specific challenge at a time. The clinician needs to encourage the client to take small steps, one at a time. The most immediate challenge facing the client is dissociation from old friends or associations. Clients must recognize the threat such encounters pose.
Establish l
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After developing a checklist of all possible challenges they will face when they enter/reenter society, they should rank them according to their immediacy. Articulating challenges by writing them down is the crux of the recovery process. Through repeated practice, it will become second nature to use the checklist after therapy has been completed.
Seven-Step Program (cont.) l
Choose l l
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The clinician must be willing to explore every possible avenue to determine what can and cannot work. Clients should be encouraged to attend community support group meetings and maintain their BARS forms l This helps in building self-reliance and reminds the client of workable strategies.
Lose l
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Because the addict must live without what has dominated their life for so long, the therapist must never allow it to paralyze them into inaction. They must be empowered with the knowledge that recovery is a journey that begins with a single step and is worth all the effort they have to expend.
Seven-Step Program (cont.) l
Act l
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Record l
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Finding out what works is a matter of trial and error and clients should be encouraged to keep trying until they find one that does. Since the BARS form keeps track of the clients daily progress, this form is especially effective when used in combination with the challenge checklist.
Evaluate l
only the client can truly judge whether he or she has been successful in dealing with a challenge. l In making their evaluation, the client should review the BARS form to assess the satisfaction level of results.
Maintain Motivation l
Recall the reasons why: l
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Clients must remind themselves of the reasons they were motivated to stop using drugs or alcohol in the first place. They should also be reminded that they never want to be that kind of person again.
Rethinking Sobriety: l
Whenever clients get off probation, they need to make an important decision by asking themselves “Why do I need sobriety at this time?” l
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The clinician can help the clients answer this question by asking questions like “Don’t you feel better now?”
Reassessing Sobriety: l
Certain challenges may cause the client to want to use again and the most helpful approach is to have the client reassess his or her choices in response
Client Recovery Expectations l
Recovering alcoholics and addicts often mistakenly think that all they have to do is just stop using and their lives will be fine. l With this mode of thinking, they may become frustrated and disappointed until they eventually relapse.
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The process must be put in perspective by: l Encouraging the clients to stop thinking negative thoughts by subvocally screaming “Stop it!� or to visualize a stop sign or a flashing stop light or a police officer. l Asking clients to verbalize and write answers to different questions and to remind them that they must learn to cope with life.
Developing Incentives l
For a recovering addict or alcoholic to sustain their motivation, clients must be provided with appropriate incentives.
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Clients should be encouraged to develop an incentives checklist dealing with specific recovery challenges l
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Includes specific goals in problem areas such as controlling temper; handling embarrassment; dealing with guilt feelings, and so on.
The goal (s) selected must be specific and achievable and activities must be non-drug-related and should give feelings of pleasure and accomplishment. To help clients act upon their incentives, they should select something from their checklist. l
As soon as a goal is accomplished, they should be encouraged to reward themselves in a non drug use activity.
Handling Feelings l
The DECLARE Model emphasizes that the client should face his or her feelings rather than avoid or mask them. l
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This is essential if the client is ever going to develop an effective coping style for living a productive life.
To help with this, it is important to: l l l
Help the client learn to relax and calm down without the use of drugs or alcohol. Ask the client, “What are you feeling?”, “Are you happy?” Encourage the client to get in touch with his/her feelings, avoiding obsessive and intrusive thoughts of drug/alcohol use, to prevent any unwanted feelings and to mitigate any feelings that are uncomfortable.
Handling Feelings (cont.) l
It should be pointed out to the client that he/she can survive the experience without any use of drugs or alcohol.
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If the client expresses feelings of fatigue or boredom, it should be suggested that they need a short break from the day or engage in a new and exciting activity. l
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The idea is to distract the client for a sufficiently long period of time so that he/she will forget about using drugs or alcohol.
There will be times when clients will continue to have difficulty with expressing feelings, which can have a negative impact on the recovery process. l
If the client says the only option is to begin using again, suggest inpatient counseling services and make the appropriate referral.
Ways of Managing Stress l
Journal Keeping l
The following questions and instructions can be used in developing a journal or daily log: l l l l l
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Take note of when you need the drug and/or alcohol Where are you feeling the discomfort? Explain what it feels like Take note of your surroundings What is your first response to the discomfort? What do you finally do?
Imagery and Self-Hypnosis l
The therapeutic use of this approach depends on the acquisition and reinforcement of several skills: l l l
Focusing attention Generating positive images Inducing a state of relaxed wakefulness
Support l
The experience of recovery is much easier if clients have people in their lives who are supportive of their efforts. l l
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This support will actually help increase the motivation level of clients. Lack of support can be harmful and may lead to the resumption of substance abuse.
Clinicians should assist clients in obtaining the information they need regarding support systems. l
It should not be automatically assumed that the client will find a support system on their own.
Selection of Support Person l
First, the client needs to articulate what type of support is required and the clinician can be of immense assistance in helping the client answer questions, such as: What is best for me at this time in my recovery? l What do I need to do to strengthen my resolve in order to remain sober? l Who has supported me in the past? l
Selection of Support Person l
Next, clients should also be cautioned in their selection of those who will lend support because not everyone can be supportive of each other. l
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The person selected needs to understand the concept of the disease, understand the commitment involved, have the time needed to provide support, committed to helping the addict and should be able to handle disappointment.
If the person in question cannot answer these questions in the affirmative, someone else should be selected
Effectiveness of Support & Support Meetings l
Clinicians must remind their clients to directly state that they are in recovery and need support. l l
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The client needs to be honest and open with others about their recovery efforts or failure is inevitable. They also should let their support persons know how much they are appreciated and how motivating it is to have them.
Clients are also encouraged to attend groups such as Alcoholics Anonymous (AA) and other support groups l
DECLARE Model views these other support groups with the highest esteem.
Managing Those Who Are Unsupportive l
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Persons in the recovery process sometimes find that others are not supportive in their efforts to remain sober. l Persons in recovery are often confronted with such “change messages” as, Why can’t it be like is used to be?, or,” We had so much fun when we got high together”. Lack of support may take the form of silence, as former drug-abusing friends of clients avoid them because they can no longer be trusted. l The client should tell unsupportive individuals how they feel about their remarks and not give in to their messages.
Craving l
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The addict’s craving for a drug is associated with dependence on it for relief of physical or psychological symptoms. The addict becomes addicted to the feeling the drug produces and not to the drug per se. l
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Rapid heart beat, tremors, perspiration and or/anxiety that characterize withdrawal may trigger cravings when reexperienced in any given situation.
Cravings are extremely difficult to handle and most chemically dependent persons develop intense fears regarding them. l
Clients need to understand that craving is not a sign of a poor prognosis, but that craving is a normal part of recovery.
Craving Intervention Plan l
The DECLARE Model offers a plan designed to stop craving once it starts based on the acronym: l
Dismantle euphoric recall: l
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this refers to an addict’s positive memories of experiences with drugs/alcohol-the client must be warned that they only signal the impulse to use again.
Escape the triggers l
Clients should be reminded to become aware of various feelings and frustrations to face their challenges and give them a sense of power and control over their lives.
Craving Intervention Plan (cont.) l
Change lifestyle and environment l all
addicts must decide to make significant changes in their world such as avoiding persons, places, things, and situations that are associated with prior use.
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Lose the fear of sobriety l to
addicts and alcoholics, the notion of living without the drug (s) is generally inconceivable and is a scary thought that creates high levels of anxiety. l The DECLARE Model recognizes this fear in their clients and should assist them in resolving it
Craving Intervention Plan (cont.) l
Accept craving as normal l persons
must learn to realize that craving is a natural part of the struggle to achieve ongoing sobriety. l Clients need to be encouraged to recognize and accept cravings as a natural occurrence in the recovery journey of every person with a substancerelated disorder. l
Relax and meditate l Methods
such as visual imagery and meditation have all the benefits and none of the side effects of drinking and using drugs.
Craving Intervention Plan (cont.) l
Exercise l Those
who become involved in daily, routine exercise programs expedite their recovery. l The physical activity is a means of replenishing the valuable neurotransmitter substances in the brain that are depleted by drug abuse. l Exercise will also reduce the tension that accompanies stress.
Relapses and Slips l
Relapse is often part of the recovery process but does not mean that all is lost or that the client is doomed to return to their former life. l l
This type of unrealistic belief will only lead to feelings of hopelessness and powerlessness. This usually begins weeks or months prior to the actual resumption of use. l
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Resumption is the predictable final stage of a relapse episode
This is a period during which the client becomes overconfident or underconfident and ends up losing control, often repeating old destructive behaviors (NBO)
A slip is considered a period during which the individual uses but is not out of control
Relapse and Slips (cont.) l
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Clients need to be told that relapse is not just using drugs and alcohol but involves a set of symptoms that create an atmosphere conducive for the return of out-of-control use. The DECLARE Model has designed a warning system of relapse based on the acronym: l Denial reactivated l after
a period of abstinence, clients believe they can begin using again but the client needs to know what’s going on in their mind and avoid the thoughts that they can return to drinking/drugging without serious consequences.
Relapses and Slips (cont.) l
Early warning signs l
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Clients should be taught to interrupt early warning signs of relapse by asking questions such as “What does it mean when I’m irritable or feeling depressed?”- many addicts and alcoholics are unable to interpret these warning signs because they are already out of control
Control l l
Clients must be encouraged to regain self-control over their thoughts, memory, and behavior. Thinking about drugs and alcohol is very dangerous because it usually places the individual in situations in which use is likely to occur. l
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Clients permit themselves to be placed in situations in which drugs and alcohol are available because “they think they can handle it”
By setting new standards, clients regain control by replacing negative thought (s) and behavior (s)
Relapses and Slips (cont.) l
Listing warning signs l
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Acting on what others say l
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Clients should be reminded that they cannot recover in isolation because they cannot realistically see what is happening and they need others for support.
Relapse education l
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Clients should be advised to make a list of any warning signs that could signal relapse such as tension, mood changes, conflicts with family, financial problems, health concerns, feelings of guilt and remorse, and cravings.
By educating themselves and increasing awareness, clients have a better-than-even chance of preventing relapse.
Entries l
it is important the clients review their daily diary or journals.
Managing this Change l
As clients decide to change and make a commitment to a new, drug-free lifestyle, a door opens to a new world full of challenges and choices. l
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How these challenges and choices are handled will ultimately determine whether they will return to their former lifestyle.
Clinicians can only guide these persons, provide encouragement, support, and hope, confident in our realization that implicit in the DECLARE Model is the letter V and the hard-won struggle it symbolizes- VICTORY. l
Working as a team, counselors and clients, with mutual respect and basic human kindness, we can all be successful !!
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QUESTIONS