IV\. Early Recovery Skills Group

**Introduction**

***Goals of Early Recovery Skills Group***

-   Provide a structured group meeting for new clients to learn about
    recovery skills and 12-Step and mutual-help programs.

-   Introduce clients to the basic tools of recovery and aid clients in
    stopping drug and alcohol use.

-   Introduce 12-Step or mutual-help involvement and create an
    expectation of participation as part of treatment.

-   Help clients adjust to participation in a group setting such as
    Relapse Prevention (RP) or Social Support group sessions or 12-Step
    or mutual-help meetings.

-   Allow the recovering co-leader to provide a model for strengthening
    initial abstinence.

-   Provide the recovering co-leader with increased self-esteem and
    reinforce his or her progress.

***Session Format and Counseling Approach***

*Counselor and Co-Leader*

The Early Recovery Skills (ERS) group is led by a counselor and co-led
by a recovering client. This co-leader is usually a current client with
more than 8 weeks of abstinence. The client must be progressing
successfully through the program, abstaining from using drugs and
drinking, and actively participating in an outside recovery group. The
counselor should invite clients from the program's RP group who meet
these criteria to fill the role of recovering co-leader. The co-leader
should be paired up with the same counselor for 3 months.

The counselor and co-leader should meet for 15 minutes before the start
of each group session to go over the session's topic and new issues
about individual clients. *No confidential information can be given to
the client co-leader. He or she is a volunteer and a client, not an
employee.* The co-leader should be instructed to share experiences about
the topic and not attempt to be a counselor. After each group session,
the counselor should debrief the co-leader to ensure that the co-leader
is refocused and stabilized, if necessary.

*Group and Session Characteristics*

The ERS component comprises eight group sessions that are held twice per
week during the first month of intensive treatment. A typical ERS group
is small (6--10 people), and sessions are relatively short
(approximately 50 minutes). ERS sessions cover a substantial amount of
material in a short time; counselors may need to move briskly from topic
to topic. This group must stay structured and on track. The counselor
and co-leader should be serious and focused and not contribute to the
high-energy, out-of-control feeling that may characterize clients in
early recovery.

The counselor begins every session by stating that the group's objective
is to teach basic abstinence skills. All clients are introduced and
asked to state how far they have progressed in treatment. First-time
participants should be given several minutes to give a brief history.
Clients giving detailed drug or alcohol histories can be interrupted
politely and asked to discuss issues that prompted treatment. Any time a
new client joins the ERS group, the counselor should explain the
importance of scheduling and marking progress, regardless of which ERS
session is the client's first. The instructions for session 1 in ERS go
into detail about scheduling. The instructions for session 2 in ERS
discuss marking progress in detail. The recovering co-leader is
introduced as someone who is currently going through the recovery
process and who can give a personal account of how the program is
working for him or her.

The ERS sessions should begin on a positive note by emphasizing benefits
that each client derives from recovery and the length of time clients
have remained abstinent. Five minutes is set aside after introductions
so clients can place a mark on their calendar handout for each day of
abstinence, share positive stories with the group, and encourage other
members.

Following the marking of progress, the counselor introduces the new
topic, tells participants which handouts from their *Client's Handbook*
they will use for the current session, gives an overview of why this
topic is important to clients' recovery and abstinence, and discusses
the topic with clients in the group. The session outlines that follow
have specific questions and suggestions to structure and enrich
discussions. The counselor should use these questions but may find that
clients have other concerns that the questions do not address. The
counselor should feel free to take the discussion in directions that
will be most helpful to the group. The recovering co-leader can relate
how each topic was useful during the early stages of his or her
recovery. The counselor should ask all participants to describe how they
can use the skills being discussed. If clients are having problems, the
counselor can solicit advice from other group members, and the counselor
and recovering co-leader can offer suggestions. About 35 minutes is
spent on group topics.

The remaining part of each ERS group session is devoted to scheduling
and to following up on the previous session's homework assignment. All
clients must have a plan for the time between the current session and
the next session. The more rigorously clients can plan, the more likely
it is that they will abide by their schedules and avoid relapse. The
goal is to map every day until the next ERS group meeting. After
scheduling is explained in the first ERS session, 5 minutes is set aside
in each session for this activity. The counselor should use part of this
time to allow clients to discuss successes and challenges with
scheduling. Specific Alcoholics Anonymous (AA), Cocaine Anonymous,
Narcotics Anonymous, or mutual-help meetings can be suggested. Clients
should be discouraged from planning activities with one another or other
clients in early recovery, except for meeting one another at 12-Step or
mutual-help meetings. Following up on clients' homework also should take
the form of a brief discussion. The counselor should strive to involve
all clients, fostering in them an interest in completing the homework
and an understanding that working on recovery takes full-time
commitment.

At the end of group sessions, any clients who will be moving on can be
given several minutes to discuss what benefits the ERS group has
provided in their first month of abstinence. Any clients who are
struggling should be able to meet briefly with their counselor or
schedule a time to do so. The recovering co-leader is not to engage in
one-on-one counseling. There is a 15-minute break between the ERS group
session and the RP group session.

***Special Considerations***

Clients in the ERS group probably have achieved only brief periods of
abstinence. Their behavior may require that the counselor sometimes
intervene and assert control in a strong, yet tactful fashion. The
examples below illustrate how to handle some common situations.

*Clients Who Spend Too Much Time Describing Episodes of Substance Use*

Failing to interrupt and redirect a client who is going into detail
about episodes of use can turn the session into an unstable experience
that might trigger some clients to relapse. The counselor should

-   Make it clear to clients new to the group that it is inappropriate
    for anyone to go into detail about episodes of substance use or
    feelings that led to using

-   Interrupt a client who begins to talk in detail about using

-   Remind the group that such talk can lead to relapse

-   Pose a new question or topic for discussion

*Clients Who Resist Participation in 12-Step, Mutual-Help, or Other
Spiritual Groups*

In discussions about 12-Step or mutual-help program involvement, clients
frequently express dissenting opinions about the value of participation.
Resistance to 12-Step or mutual-help group involvement is an important
issue. To address client concerns, the counselor should

-   State clearly that the treatment outcome for people who attend
    12-Step or mutual-help programs is better than for people who do
    not. The Matrix Institute has conducted several surveys on treatment
    outcomes and 12-Step or mutual-help program involvement and
    consistently has found a strong positive relationship. However,
    clients may state that they do not find meetings helpful and are not
    going to attend.

-   Acknowledge that it is not uncommon for people initially to find
    participating in such programs uncomfortable.

-   Avoid arguing with reluctant clients or trying to compel them to
    attend 12-Step meetings.

-   Provide clients with a list of local meetings and encourage clients
    to attend different meetings until they find one that feels
    comfortable.

-   Encourage clients who are resistant to the spiritual aspects of
    12-Step or mutual-help programs to attend for the fellowship and
    support. Social activities, coffee after the meetings, and the
    availability of others to call in times of trouble are encouraging
    aspects of participation for ambivalent members.

Those who feel uncomfortable going to unfamiliar meetings in the
community may want to attend them with the recovering co-leader or other
group members. Program graduates may want to start a 12-Step meeting at
the treatment center, providing clients with a way to become familiar
with 12-Step or mutual-help group philosophies and meeting structures
while in a familiar environment.

Some clients may be willing to attend 12-Step meetings but resist
getting a sponsor and working the steps. It is important to allow
clients to engage in 12-Step activities on their schedules, when they
are ready. The more involved clients are in a 12-Step or mutual-help
program, the stronger their recovery is likely to be. Clients should
choose a sponsor who is accepting of concurrent involvement in
professional treatment.

Clients who are looking for an alternative to traditional 12-Step
programs should be encouraged to explore the following groups:

-   Women for Sobriety (www.womenforsobriety.org) helps women overcome
    alcohol dependence through emotional and spiritual growth.

-   Jewish Alcoholics, Chemically Dependent Persons and Significant
    Others (JACS) (www.jacsweb.org) helps people explore recovery in a
    nurturing Jewish environment.

-   Self-Management and Recovery Training (SMART)
    (www.smartrecovery.org) is a cognitive--behavioral group approach
    that focuses on self-reliance, problemsolving, coping strategies,
    and a balanced lifestyle.

-   Secular Organizations for Sobriety (www.secularhumanism.org)
    maintains that sobriety is a separate issue from religion or
    spirituality and credits the individual for achieving and
    maintaining sobriety.

-   Community-based spiritual fellowships, which take place in churches,
    synagogues, mosques, temples, and other spiritually focused meeting
    sites, often form the basis for support, lifestyle change, and
    clarification of values in peoples' lives.

The counselor should consult local directories for these groups and be
prepared to provide contact information, if clients request.

Note: The list of alternatives to 12-Step programs is referred to in
session 4 and session 8 of ERS and in session 30 of RP. The counselor
should take a copy of this list to every session, in case a client
requests information.

*Clients Who Provide Inaccurate or Dangerous Suggestions to Other
Clients*

Clients sometimes may provide suggestions during group meetings that are
inaccurate or possibly dangerous. When a client makes a potentially
harmful recommendation to another client, the counselor

-   Maintains a polite and respectful attitude toward all members of the
    group while remaining clearly in control

-   Redirects the conversation as in the example that follows

Client A states that her prescribed antidepressants are not helping with
her depression and are making her tired. Client B says, "You should
really just stop taking your antidepressants. If you're tired, you may
end up relapsing to meth because you can't stay awake during the day.
You've worked so hard to quit using meth and remain abstinent." The
counselor should step in at this point to address the situation. "Client
B, although I know you have good intentions, Client A needs to discuss
her medication with her doctor. But you raise an important point: being
tired can be a trigger for relapse. Let's talk about how thought
stopping can help you cope with triggers when they arise."

*Clients Who Cannot Take Direction or Limit Their Input*

Sometimes, unstable clients are unable to take subtle direction or
appropriately limit their input. In situations such as these, the
counselor should

-   Defuse the situation by saying something like, "You have a lot of
    energy tonight. Let's make sure everyone has a chance to talk. Just
    listen for a while."

-   Address the client directly and ask the client to cease the
    disruptive behavior, if the counselor's attempt to defuse the
    situation does not succeed.

-   Ask the client to leave the group for that session, if the
    disruptive behavior continues.

-   Speak with the client alone after the group meeting about his or her
    specific problem, if possible.

A client who is disruptive or out of control may be experiencing an
attention deficit disorder or a more serious mental disorder. Counselors
should be alert to the possibility of co-occurring substance use and
mental disorders and make referrals to appropriate psychiatric care when
necessary.

*Clients Who Appear Intoxicated*

If a client seems intoxicated, the counselor should

-   Ask the client to step outside the session room with the counselor.
    The recovering co-leader can continue the group while the counselor
    attempts to evaluate the client's condition and discusses the
    circumstances leading to the drug or alcohol use, if no other
    counselor is available or the client is not capable of engaging in
    treatment.

-   Help the client find another counselor on site who can work with the
    client, if the client is capable of engaging productively in
    one-on-one treatment.

-   Ensure that the client has safe transportation home and forgo any
    discussion of the matter until the next treatment appointment,
    depending on the degree of the client's intoxication.

-   Avoid confrontation.

*Clients Who Relapse*

Clients who are beyond the first month of treatment but have relapsed
and are struggling to impose structure on their recovery may benefit
from repeating the ERS group while they attend RP sessions. Once the
counselor determines that these clients have stabilized, they may stop
attending ERS sessions and attend only RP sessions.

*Rational Brain Versus Addicted Brain*

The ERS group session descriptions use the metaphorical struggle between
a client's rational brain and addicted brain as a way to talk about
recovery. The terms *rational brain* and *addicted brain* do not
correspond to physiological regions of the brain, but they give clients
a way to conceptualize the struggle between the desire to stay committed
to recovery and the desire to begin using stimulants again.

*Adapting Client Handouts*

Client handouts are written in simpler language than the session
descriptions for counselors. The client materials should be
understandable for someone with an eighth grade reading level. Difficult
words (e.g., *abstinence, justification*) are occasionally used.
Counselors should be prepared to help clients who struggle with the
material. Counselors should be aware that handouts will need to be
adapted for clients with reading difficulties.

***Session Descriptions***

The following sections provide structured guidance to the counselor for
organizing and conducting the eight ERS group sessions in the intensive
outpatient program. The handouts indicated in the session guidance are
provided after the session descriptions for the counselor's use and are
duplicated in the *Client's Handbook.* Figure IV-1 provides an overview
of the eight ERS sessions.

+-------+-------------+------------------------------------------------+
| **F   |             |                                                |
| igure |             |                                                |
| IV-1. |             |                                                |
| Early |             |                                                |
| Rec   |             |                                                |
| overy |             |                                                |
| S     |             |                                                |
| kills |             |                                                |
| Ses   |             |                                                |
| sions |             |                                                |
| Overv |             |                                                |
| iew** |             |                                                |
+=======+=============+================================================+
| *     | **Topic**   | **Content**                                    |
| *Sess |             |                                                |
| ion** |             |                                                |
|       |             |                                                |
| **Num |             |                                                |
| ber** |             |                                                |
+-------+-------------+------------------------------------------------+
| 1     | Stop the    | Clients learn about triggers and cravings and  |
|       | Cycle       | how they are related to substance use. Clients |
|       |             | learn to use thought-stopping techniques to    |
|       |             | disrupt relapse and scheduling to organize     |
|       |             | their recovery.                                |
+-------+-------------+------------------------------------------------+
| 2     | Identifying | Clients learn to identify their external       |
|       | External    | triggers and that charting their external      |
|       | Triggers    | triggers can help prevent relapse.             |
+-------+-------------+------------------------------------------------+
| 3     | Identifying | Clients learn to identify their internal       |
|       | Internal    | triggers and that charting their internal      |
|       | Triggers    | triggers can help prevent relapse.             |
+-------+-------------+------------------------------------------------+
| 4     | Introducing | Clients learn about the format, benefits, and  |
|       | 12-Step or  | challenges of 12-Step programs and about       |
|       | Mutual-Help | 12-Step meetings in their area. Clients also   |
|       | Activities  | learn about alternatives to 12-Step meetings,  |
|       |             | such as mutual-help groups.                    |
+-------+-------------+------------------------------------------------+
| 5     | Body        | Clients learn that their bodies must adjust to |
|       | Chemistry   | recovery as they work through the stages of    |
|       | in Recovery | recovery. Clients identify ways to overcome    |
|       |             | the physical challenges posed by recovery.     |
+-------+-------------+------------------------------------------------+
| 6     | Common      | Clients learn new coping techniques that do    |
|       | Challenges  | not involve substance use. Clients identify    |
|       | in Early    | challenging situations and ways to address     |
|       | Recovery    | them that help maintain abstinence.            |
+-------+-------------+------------------------------------------------+
| 7     | Thinking,   | Clients learn how thoughts and emotions        |
|       | Feeling,    | contribute to behavior and that responses to   |
|       | and Doing   | thoughts and emotions can be controlled.       |
|       |             | Clients identify behaviors that are related to |
|       |             | substance use.                                 |
+-------+-------------+------------------------------------------------+
| 8     | 12-Step     | Clients learn 12-Step sayings and identify     |
|       | Wisdom      | situations in which they will use them.        |
|       |             | Clients also learn to recognize when they are  |
|       |             | most vulnerable to relapse.                    |
+-------+-------------+------------------------------------------------+

**Session 1: Stop the Cycle**

## *Goals of Session*

-   Help clients understand what triggers and cravings are.

-   Help clients identify individual triggers.

-   Help clients understand how triggers and cravings can lead to use.

-   Help clients learn techniques for stopping thoughts that can lead to
    use.

-   Help clients learn the importance of scheduling time.

### *Handouts*

-   ERS 1A---Triggers

-   ERS 1B---Trigger--Thought--Craving--Use

-   ERS 1C---Thought-Stopping Techniques

-   SCH 1---The Importance of Scheduling

-   SCH 2---Daily/Hourly Schedule

### *Topics for Group Discussion (35 minutes)*

1.  *Discussing the Concept of Triggers*

> Over time certain people, places, things, situations, and even
> emotions become linked with substance use in the mind of the person
> who abuses substances. Being around those triggers can bring on a
> craving for the substance, which can lead to use.

-   Go over handout ERS 1A---Triggers.

-   Ask clients to identify their triggers on the handout.

-   Discuss specific things that have acted as triggers for clients.

-   Ask clients to think about possible triggers they will face when
    they leave the program.

-   Introduce the importance of scheduling to avoid triggers; the last
    15 minutes of this session (and the last 5 minutes of every other
    ERS session) is devoted to clients' scheduling their time from the
    end of one session to the beginning of the next.

2.  *Discussing Cravings*

Cravings are impulsive urges to use that have a physiological basis.
Cravings will not stop just because clients have decided not to use.
Clients will need to alter their behavior to avoid the triggers that can
lead to cravings. Planning for behavior changes will accomplish much
more than mere good intentions and strong commitment will.

-   Discuss how clients will have to change their behaviors to avoid
    triggering cravings.

-   Discuss the importance of removing paraphernalia associated with
    substance use.

-   Ask what changes clients already have made to reduce cravings. What
    effect have these changes had?

-   Have the recovering co-leader discuss how the intensity of cravings
    has changed over time as a result of behavior changes. It is
    important for clients to know that cravings will subside eventually.

3.  *Discussing the Principle of Thought Stopping*

In addition to changing behaviors to avoid triggers, clients can
interrupt the sequence that leads from trigger to thinking about using
to craving and then to using. Even though the triggering of cravings
seems like an automatic process, clients still can avoid using by
stopping their thoughts about using.

-   Go over handout ERS 1B---Trigger--Thought--Craving--Use.

-   Help clients understand that cravings do not have to overwhelm them;
    they can block the thoughts that lead to cravings.

-   Have clients discuss the images that will help them stop their
    thoughts of using.

4.  *Discussing and Practicing Thought-Stopping Techniques*

> Thought stopping is a useful skill if clients practice it. When they
> encounter a trigger to use, clients must be able to use
> thought-stopping techniques to break the link between thinking of
> using and cravings. Clients should know that triggers do not
> *automatically* lead to using; by stopping their thoughts, clients can
> choose not to use.

-   Go over handout ERS 1C---Thought-Stopping Techniques.

-   Discuss with clients which of the four techniques (visualization,
    snapping, relaxation, calling someone) they think will be most
    helpful to them.

-   Solicit suggestions for concrete applications of the techniques.
    What will clients visualize? What will they do to relax? Whom will
    they call?

-   Make it clear to clients that thought-stopping techniques will hold
    cravings at bay, buying clients time until they can take action
    (e.g., go to a meeting, work out at a gym).

-   Have clients suggest other techniques that might help them stop
    their thoughts about using (e.g., taking a walk, going to a movie,
    taking a bath).

-   Emphasize to clients that cravings will pass; most only last 30 to
    90 seconds.

-   Have the co-leader discuss thought-stopping techniques that work for
    him or her.

## *Scheduling (15 minutes)*

One of the main goals of scheduling is to ensure that the rational part
of clients' brains takes charge of their behavior rather than the
emotional addicted part of their brains where cravings start. When
clients make a schedule and stick to it, they put their rational brains
in charge. People in outpatient treatment need to structure their time
if they are serious about recovery. It is important for clients to plan
their activities and to write them down in their schedules. Schedules
that exist only in one's head are too easy to revise or abandon. Clients
need to schedule every hour of the day and stick to the schedule. When
clients are making their schedules, special attention should be paid to
weekends and any other times clients feel they are particularly
vulnerable to substance use.

-   Go over handout SCH 1---The Importance of Scheduling.

-   Help clients understand that scheduling their time rigorously and
    sticking to the schedule are part of the recovery process.
    Scheduling will help clients' rational brains govern their behavior
    and aid them in making good decisions.

-   Have clients complete handout SCH 2---Daily/Hourly Schedule;
    encourage them to be thorough in their scheduling, leaving no holes
    in their schedules.

Clients will undertake this scheduling exercise at the close of all
eight sessions in the ERS portion of treatment. Fifteen minutes is
allotted to this activity in session 1 so that the counselor can
introduce it. In sessions 2 through 8, 5 minutes is devoted to
scheduling, and a new activity---marking progress---is added to the
beginning of each session.

#### ***Homework***

Encourage clients to use pages 6 and 7 of their *Client's Treatment
Companion* to keep a log of the triggers they encounter and how they
combat them. Encourage clients to keep a list of thought-stopping
techniques that work best for them.

# **Session 2: Identifying External Triggers**

## *Goals of Session*

-   Help clients understand what external triggers are.

-   Help clients identify individual external triggers.

-   Help clients understand how external triggers can lead to use.

-   Help clients review the need for scheduling to avoid external
    triggers.

-   Help clients learn the importance of marking recovery progress.

### *Handouts*

-   CAL 1---Marking Progress

-   CAL 2---Calendar

-   ERS 2A---External Trigger Questionnaire

-   ERS 2B---External Trigger Chart

-   SCH 2---Daily/Hourly Schedule

## *Marking Progress (5 minutes)*

Keeping a daily record of abstinence keeps clients mindful that their
recovery is a day-to-day process. Marking progress also allows clients
to take pride in how far they have come. Clients who are newly abstinent
may experience a distortion in which time seems to pass more slowly than
when they were using substances. Charting their progress in short units
may make the daunting process of recovery seem more manageable. The
first 5 minutes of each session in the ERS portion of treatment is
devoted to this activity.

-   Go over handout CAL 1---Marking Progress.

-   Have clients place a checkmark on each day on handout CAL
    2---Calendar for which they have not used substances.

### 

### *Topics for Group Discussion (35 minutes)*

1.  *Discussing the Concept of External Triggers*

In session 1, clients learned what triggers are and identified and
discussed specific triggers. Now they undertake a more detailed
examination of situations and circumstances that are linked to using
substances. The counselor helps clients understand that external
triggers are aspects of their lifestyle and the choices they make that
are under their control. These are things that they can change.

-   Go over handout ERS 2A---External Trigger Questionnaire.

-   Have clients place a checkmark next to all external triggers that
    apply to them and a zero next to those that do not.

-   Encourage clients to think of external triggers that are not on the
    handout and list these separately.

-   Have clients list situations and people who are not linked with
    substance use for them (i.e., who are "safe").

-   Discuss clients' external triggers.

-   Review the method for responding to triggers discussed in session 1
    (ERS 1C---Thought-Stopping Techniques).

-   Review the importance of scheduling to avoid triggers.

2.  *Charting External Triggers*

Now that clients have made lists of their external triggers and of those
people, places, and situations that are "safe," clients can classify
them according to the strength of their association with substance use.
Completing the External Trigger Chart (ERS 2B) helps clients realize
that an episode of using substances is not set off by random events.
Clients also realize that they have the knowledge to help themselves
avoid substance use. By altering their behavior, clients can exercise
control and reduce the chances of using substances. The counselor can
encourage clients to bring this chart (and ERS 3B---Internal Trigger
Chart \[discussed in session 3\]) to their individual counseling
sessions to help address issues with triggers. Clients should keep this
chart handy and add triggers to it, if new triggers arise (see Homework
below).

-   Go over handout ERS 2B---External Trigger Chart.

-   Have clients list people, things, and situations on the chart,
    rating them for their potential as triggers.

-   Encourage clients to share those items that are particularly
    troublesome and those that they feel are "safe."

-   Have the recovering co-leader discuss how using the External Trigger
    Chart has helped him or her understand and gain control of triggers.

## *Scheduling (5 minutes)*

The counselor should remind clients that scheduling their time
rigorously and sticking to the schedule are part of the recovery
process. People who abuse substances are not accountable to schedules;
taking responsibility for sticking to a schedule helps clients stop
using. Following through on decisions made during scheduling helps keep
clients' rational brains in charge of behavior.

-   Ask clients how the schedule they made at the end of the previous
    session helped them remain drug free.

-   Ask clients what they learned about scheduling that will affect how
    they make future schedules.

-   Have clients complete handout SCH 2---Daily/Hourly Schedule for the
    time between this session and session 3.

#### ***Homework (5 minutes)***

Ask clients to share briefly their experience of doing the homework from
the previous session. The counselor can decide how detailed the followup
on homework should be. The goal of asking is not to discover which
clients have not done the homework but to encourage clients to work on
their recovery between sessions and to share that work with the group.

Encourage clients to update their list of external triggers on handout
ERS 2B---External Trigger Chart as their recovery continues.

# **Session 3: Identifying Internal Triggers**

## *Goals of Session*

-   Help clients understand what internal triggers are.

-   Help clients identify individual internal triggers.

-   Help clients understand how internal triggers can lead to use.

-   Help clients understand the individual thoughts and emotions that
    act as triggers.

-   Help clients review the importance of scheduling and marking
    progress.

### *Handouts*

-   CAL 2---Calendar

-   ERS 3A---Internal Trigger Questionnaire

-   ERS 3B---Internal Trigger Chart

-   SCH 2---Daily/Hourly Schedule

## *Marking Progress (5 minutes)*

Before introducing the session topics, the counselor gives clients time
to chart their progress on CAL 2---Calendar and encourages clients to
share positive events they have experienced since the last session.

### *Topics for Group Discussion (35 minutes)*

1.  *Discussing the Concept of Internal Triggers*

> In session 1 clients learned what triggers are and identified and
> discussed specific triggers. Now they undertake a more detailed
> examination of thoughts and emotions that are linked with using
> substances. Early recovery can be a chaotic time, especially
> emotionally. Many clients may feel depression, shame, fear, confusion,
> or self-doubt. Although clients may feel that their thoughts and
> emotions are not under their control during this time, the counselor
> can help clients understand that how they respond to those internal
> triggers *is* under their control.

-   Go over handout ERS 3A---Internal Trigger Questionnaire.

-   Have clients place a checkmark next to all internal triggers that
    apply to them and a zero next to those that do not. Clients also
    should include thoughts or emotions that once acted as triggers,
    even if they no longer do.

-   Have clients complete the rest of the handout, with special
    attention to thoughts or emotions that have triggered recent use.

-   Discuss clients' internal triggers. As clients describe their
    internal states, reflect back what they say and ask whether it is
    accurate.

-   Review the method for responding to triggers discussed in session 1
    (ERS 1C---Thought-Stopping Techniques).

-   Discuss other ways that clients can cope with triggers. If a certain
    internal state is no longer a problem for a client, have that client
    share how he or she got control over the internal trigger.

2.  *Charting Internal Triggers*

Now that clients have listed their internal triggers, they should
classify the triggers according to the strength of their association
with substance use, just as they did for their external triggers.
Charting their internal triggers allows clients to identify particularly
safe and unsafe emotional states, which, in turn, should help them
anticipate and head off problems. Completing the Internal Trigger Chart
(ERS 3B) helps clients visualize the choices they make and the
consequences of those choices. By seeking to avoid situations that
provoke dangerous emotions, clients can exercise control over their
recovery. The counselor can encourage clients to bring this chart (and
ERS 2B---External Trigger Chart) to their individual counseling sessions
to help address issues with triggers. Clients should keep the Internal
Trigger Chart handy and add triggers to it, if new triggers arise (see
Homework below).

-   Go over handout ERS 3B---Internal Trigger Chart.

-   Have clients list thoughts and emotions on the chart, rating them
    for their potential as triggers.

-   Encourage clients to share the items that are particularly
    troublesome and those that they feel are "safe."

-   Have the recovering co-leader discuss how using the Internal Trigger
    Chart has helped him or her understand and gain control of triggers.

## *Scheduling (5 minutes)*

The counselor should remind clients that scheduling their time
rigorously and sticking to the schedule are part of the recovery
process. People who abuse substances are not accountable to schedules;
taking responsibility for sticking to a schedule helps clients stop
using. Following through on decisions made during scheduling helps keep
clients' rational brains in charge of behavior.

-   Ask clients how the schedule they made at the end of the previous
    session helped them remain drug free.

-   Ask clients what they learned about scheduling that will affect how
    they make future schedules.

-   Have clients complete handout SCH 2---Daily/Hourly Schedule for the
    time between this session and session 4.

#### ***Homework (5 minutes)***

Ask clients to share briefly their experience of doing the homework from
the previous session. The counselor can decide how detailed the followup
on homework should be. The goal of asking is not to discover which
clients have not done the homework but to encourage clients to work on
their recovery between sessions and to share that work with the group.

Encourage clients to update their list of internal triggers on handout
ERS 3B---Internal Trigger Chart as their recovery continues.

# **Session 4: Introducing 12-Step or Mutual-Help Activities**

## *Goals of Session*

-   Help clients understand the structure and format of 12-Step
    programs.

-   Help clients identify the challenges and benefits of participating
    in 12-Step programs.

-   Help familiarize clients with options for local 12-Step meetings.

-   Help clients recognize that participation in 12-Step or mutual-help
    programs is integral to recovery.

-   Help clients review the importance of scheduling and marking
    progress.

### *Handouts*

-   CAL 2---Calendar

-   ERS 4A---12-Step Introduction

-   ERS 4B---The Serenity Prayer and the 12 Steps of Alcoholics
    Anonymous

-   SCH 2---Daily/Hourly Schedule

## *Marking Progress (5 minutes)*

Before introducing the session topics, the counselor gives clients time
to chart their progress on CAL 2---Calendar and encourages clients to
share positive events they have experienced since the last session.

### *Topics for Group Discussion (35 minutes)*

1.  *Discussing Clients' Prior Participation in 12-Step or Mutual-Help
    Programs*

> Participation in a 12-Step or mutual-help program during and after
> treatment is central to recovery. Clients should view 12-Step or
> mutual-help group participation as important to their recovery as
> attending treatment sessions. Research shows that a combination of
> professional substance abuse treatment and participation in 12-Step
> support groups is often the most effective route to recovery. The most
> important aspect of 12-Step or mutual-help group participation is that
> it surrounds clients with supportive people who are going through the
> same struggles. Participation in a 12-Step or mutual-help group also
> reinforces the message that recovery is not an individual process. The
> client must do the work of quitting substance use, but the knowledge
> and support of others who have remained abstinent are essential to
> recovery.

-   Ask how many clients have participated in 12-Step or mutual-help
    programs.

-   Ask those who have participated to share *briefly* their negative
    experiences with meetings. The recovering co-leader can start this
    discussion, if clients are reticent. Negative experiences might
    include the following:

    -   Some people in meetings are not interested in change.

    -   It is hard to reveal problems, even (or especially) in front of
        strangers.

    -   The structure is too rigid.

    -   Meetings are too time consuming.

    -   The spiritual elements are intrusive.

    -   Going to meetings can make one feel like using again.

        -   Ask clients who have *not* attended meetings to express
            their concerns about 12-Step or mutual-help group
            participation.

        -   Ask clients who have participated in 12-Step or mutual-help
            programs to share their positive experiences. Again, the
            recovering co-leader can initiate this discussion.

2.  *Discussing Clients' Knowledge of 12-Step Programs*

The preceding discussion gives the counselor a good idea of clients'
understanding of the structure and processes of 12-Step meetings.
Meetings can have different characteristics. If clients do not feel that
the first meeting they try suits them, they should try to find one with
which they are more comfortable. It is important for clients to know
that many different types of meetings are available, especially in
metropolitan areas, including language-specific meetings,
gender-specific meetings, open meetings, meetings based on participants'
sexual orientation, and meetings for people who also have a mental
disorder ("double trouble" or Dual Recovery Anonymous meetings).

-   Go over handout ERS 4A---12-Step Introduction.

-   Go over handout ERS 4B---Serenity Prayer and the 12 Steps of
    Alcoholics Anonymous.

-   Emphasize that meetings are not *religious* but spiritual. Clients
    decide for themselves what the higher power of the 12 Steps refers
    to. Metropolitan areas may have special secular 12-Step meetings.
    Crystal Meth Anonymous (CMA) is a 12-Step program for people who are
    in recovery from methamphetamine dependence. CMA meetings can be
    found in many large cities and some smaller communities, especially
    in the West, Midwest, and South.

-   Early in recovery, encourage clients to find a home meeting and
    attend as many meetings as their schedule permits.

-   Stress the importance of finding and working with a sponsor.

-   Have the recovering co-leader tell his or her story of finding a
    12-Step meeting to attend and how doing so has helped him or her.

-   Share with clients information about the 12-Step programs in the
    area. Ensure that you are knowledgeable about the characteristics of
    each group program. Provide a list of programs---with addresses,
    phone numbers, contacts, and a brief description---to each client.

3.  *Introducing Alternative Mutual-Help Groups*

The counselor should research local options to 12-Step programs and
expose clients to other types of recovery support in addition to 12-Step
programs. Many clients find help from the organizations listed on pages
44 and 45.

## *Scheduling (5 minutes)*

The counselor should remind clients that scheduling their time
rigorously and sticking to the schedule are part of the recovery
process. People who abuse substances are not accountable to schedules;
taking responsibility for sticking to a schedule helps clients stop
using. Following through on decisions made during scheduling helps keep
clients' rational brains in charge of behavior.

-   Ask clients how the schedule they made at the end of the previous
    session helped them remain drug free.

-   Ask clients what they learned about scheduling that will affect how
    they make future schedules.

-   Have clients complete handout SCH 2---Daily/Hourly Schedule for the
    time between this session and session 5.

#### ***Homework (5 minutes)***

Ask clients to share briefly their experience of doing the homework from
the previous session. The counselor can decide how detailed the followup
on homework should be. The goal of asking is not to discover which
clients have not done the homework but to encourage clients to work on
their recovery between sessions and to share that work with the group.

Encourage clients to attend at least one 12-Step or mutual-help meeting
before session 5.

# **Session 5: Body Chemistry in Recovery**

## *Goals of Session*

-   Help clients understand that recovery is a physical process that
    requires the body to adjust.

-   Help clients understand specific physical symptoms that may occur
    during recovery.

-   Help clients identify the stages of recovery and the challenges
    associated with them.

-   Help clients consider ways to overcome the physical challenges of
    early recovery.

### *Handouts*

-   CAL 2---Calendar

-   ERS 5---Roadmap for Recovery

-   SCH 2---Daily/Hourly Schedule

## *Marking Progress (5 minutes)*

Before introducing the session topics, the counselor gives clients time
to chart their progress on CAL 2---Calendar and encourages clients to
share positive events they have experienced since the last session.

### *Topics for Group Discussion (35 minutes)*

1.  *Discussing Recovery as a Physical Process*

> In addition to experiencing behavioral and emotional changes while in
> recovery, clients also experience physical changes. Clients' bodies
> also must adjust. The chemistry of the brain is altered by habitual
> substance use; clients can think of this adjustment period as a
> "healing" of the brain. During early recovery clients may experience
> symptoms such as depression, low energy, sleep disturbances,
> headaches, and anxiety. These symptoms are part of the body's healing
> process. If clients understand this, they are better able to focus on
> their recovery. Good nutrition, exercise, sufficient sleep,
> relaxation, and leisure activities to reduce stress may be beneficial,
> particularly during the early stages of recovery.

-   Ask clients to share their experiences with prior attempts at
    recovery.

-   Ask clients what physical symptoms they experienced during recovery.
    How long did these symptoms persist?

-   Ask the recovering co-leader to share personal experiences of the
    physical difficulties of early recovery. What strategies or
    activities helped the recovering co-leader through the physical
    discomfort of early recovery?

2.  *Discussing the Stages of Recovery*

Recovery from stimulant use can be divided into four stages: withdrawal,
early abstinence (a.k.a. the Honeymoon), protracted abstinence (a.k.a.
the Wall), and readjustment. These four stages were originally developed
to describe recovery from cocaine addiction. The length of time for
various stages may vary for other stimulants. For example, because
methamphetamine has a longer half-life in the body than cocaine,
recovery from methamphetamine will lag behind the time periods listed on
handout ERS 5---Roadmap for Recovery. The stages are a rough outline of
the progress of recovery, and every client's experience is different.
However, being familiar with the typical changes and challenges that
come with recovery helps prepare clients for them.

-   Go over handout ERS 5---Roadmap for Recovery. Explain to clients
    that the time periods listed provide a general outline of recovery
    and that their recovery may take slightly longer.

-   For each stage, focus on the substances that people in the group had
    been using (e.g., if no one in the group used opioids, focus on
    stimulants and alcohol).

-   Ask clients to discuss the symptoms they are experiencing.

-   Caution clients about the intense cravings and risk of impulsive
    actions during the first 2 weeks of abstinence---the withdrawal
    stage. Also be certain that clients are aware of the challenges
    posed by the stage known as the Wall. Most relapses occur during one
    of these two stages.

-   Remind clients of the need to continue attending treatment sessions
    and 12-Step or mutual-help meetings, even if, after several weeks of
    abstinence, they feel as if their substance use is behind them.

## *Scheduling (5 minutes)*

The counselor should remind clients that scheduling their time
rigorously and sticking to the schedule are part of the recovery
process. People who abuse substances are not accountable to schedules;
taking responsibility for sticking to a schedule helps clients stop
using. Following through on decisions made during scheduling helps keep
clients' rational brains in charge of behavior.

-   Ask clients how the schedule they made at the end of the previous
    session helped them remain drug free.

-   Ask clients what they learned about scheduling that will affect how
    they make future schedules.

-   Have clients complete handout SCH 2---Daily/Hourly Schedule for the
    time between this session and session 6.

#### ***Homework (5 minutes)***

Ask clients to share briefly their experience of doing the homework from
the previous session. The counselor can decide how detailed the followup
on homework should be. The goal of asking is not to discover which
clients have not done the homework but to encourage clients to work on
their recovery between sessions and to share that work with the group.

Encourage clients to try one new activity or strategy to combat the
physical symptoms of early abstinence. Remind them to eat well,
exercise, get enough sleep, and try new leisure activities.

# **Session 6: Common Challenges in Early Recovery**

## *Goals of Session*

-   Help clients understand that it is necessary to find new coping
    techniques that do not involve substance use.

-   Help clients identify challenges and new solutions that maintain
    abstinence.

-   Help clients understand the importance of stopping alcohol use.

### *Handouts*

-   CAL 2---Calendar

-   ERS 6A---Five Common Challenges in Early Recovery

-   ERS 6B---Alcohol Arguments

-   SCH 2---Daily/Hourly Schedule

## *Marking Progress (5 minutes)*

Before introducing the session topics, the counselor gives clients time
to chart their progress on CAL 2---Calendar and encourages clients to
share positive events they have experienced since the last session.

### *Topics for Group Discussion (35 minutes)*

1.  *Discussing Challenges Clients Often Face in Early Recovery*

> Many aspects of clients' lives require change if clients are to
> maintain abstinence. But certain areas and situations have proved to
> be particularly troublesome for people in recovery. Examining the five
> challenges listed on ERS 6A and discussing solutions help clients
> address these challenges more effectively. In the past, clients
> probably turned to substance use when they encountered one of these
> problem situations. Part of the recovery process is learning a new
> repertoire of responses to cope with these situations. Recovery
> consists of assembling new coping techniques one solution at a time.
> The wider the variety of coping techniques clients can call on, the
> better they are able to manage their problems.

-   Go over handout ERS 6A---Five Common Challenges in Early Recovery
    with clients.

-   Ask clients what solutions they think will be helpful to them when
    they face these scenarios. Do clients have suggested solutions that
    are not listed?

-   Ask clients which challenges are particularly troublesome. How do
    they plan to address them?

-   Ask the recovering co-leader to discuss how he or she handled these
    common early recovery challenges.

-   Remind clients of the importance of scheduling. Many of the
    solutions on the handout involve planning abstinent outings or
    setting aside time for new activities. Rigorous scheduling helps
    clients maintain their abstinence.

2.  *Discussing the Importance of Stopping Alcohol Use*

Some clients have problems giving up alcohol; some feel that giving up
stimulants is enough work without making another major life adjustment.
As discussed in session 5, when the Honeymoon stage ends after about 6
weeks of treatment, clients may experience intense cravings for
stimulants. This also is the time when many clients return to alcohol
use. Seeing no connection between alcohol and stimulants, clients may
try to rationalize their return to alcohol use. It is important for
clients to understand that it is necessary to abstain from alcohol to
allow the brain to heal and that abstaining from alcohol will help them
abstain from stimulants.

-   Go over handout ERS 6B---Alcohol Arguments.

-   Ask clients whether they have had some of these "arguments" with
    themselves. What other rationalizations for using alcohol have
    clients faced?

-   Ask clients how they have responded to these rationalizations.

-   Draw on the recovering co-leader's experience to help clients
    address their rationalizations of a return to alcohol use. What
    strategies has the co-leader used to abstain from alcohol?

## *Scheduling (5 minutes)*

The counselor should remind clients that scheduling their time
rigorously and sticking to the schedule are part of the recovery
process. People who abuse substances are not accountable to schedules;
taking responsibility for sticking to a schedule helps clients stop
using. Following through on decisions made during scheduling helps keep
clients' rational brains in charge of behavior.

-   Ask clients how the schedule they made at the end of the previous
    session helped them remain drug free.

-   Ask clients what they learned about scheduling that will affect how
    they make future schedules.

-   Have clients complete handout SCH 2---Daily/Hourly Schedule for the
    time between this session and session 7.

***Homework (5 minutes)***

Ask clients to share briefly their experience of doing the homework from
the previous session. The counselor can decide how detailed the followup
on homework should be. The goal of asking is not to discover which
clients have not done the homework but to encourage clients to work on
their recovery between sessions and to share that work with the group.

When clients are confronted with a problem, encourage them to try one of
the alternatives discussed on handout ERS 6A---Five Common Challenges in
Early Recovery. In addition to the arguments listed on handout ERS
6B---Alcohol Arguments, have clients think of another argument for
remaining abstinent from alcohol and record it in their *Client's
Treatment Companion* on page 8.

# **Session 7: Thinking, Feeling, and Doing**

## *Goals of Session*

-   Help clients understand the connections among thoughts, emotions,
    and behavior.

-   Help clients understand how thoughts and emotions contribute to
    behavior.

-   Help clients understand that responses to thoughts and emotions can
    be controlled.

-   Help clients identify behaviors that are related to substance use.

### *Handouts*

-   CAL 2---Calendar

-   ERS 7A---Thoughts, Emotions, and Behavior

-   ERS 7B---Addictive Behavior

-   SCH 2---Daily/Hourly Schedule

## *Marking Progress (5 minutes)*

Before introducing the session topics, the counselor gives clients time
to chart their progress on CAL 2---Calendar and encourages clients to
share positive events they have experienced since the last session.

### *Topics for Group Discussion (35 minutes)*

1.  *Discussing Connections Among Thoughts, Emotions, and Behavior*

> Many people assume that thoughts and emotions happen outside their
> control. Because they feel that they cannot influence or change their
> thoughts and emotions, these people may not consider the effects that
> their thoughts and emotions can have on behavior. In session 1, the
> group discussed how emotions can act as triggers for substance use and
> how thoughts, if not stopped, can lead to cravings. It is important
> for clients to become aware of thoughts and emotions, to be able to
> observe and analyze them. Clients can look for patterns in their
> thoughts and emotions. They also can pay attention to how their
> thoughts and feelings are expressed in body language, physical
> changes, and behavior. Attuned to their thoughts and feelings, clients
> are better able to recognize which thoughts and emotions are connected
> to substance use. This recognition helps clients exercise control over
> their responses.

-   Go over handout ERS 7A---Thoughts, Emotions, and Behavior.

-   Ask clients about the differences between thoughts and emotions. How
    do clients respond to each?

-   Review thought-stopping techniques, and ask clients to share the
    visualizations they use to stop thoughts of using.

-   State that usually positive emotions (e.g., excitement, joy,
    gratitude) are considered good things. What are some positive
    emotions that can lead to substance use?

-   Ask the recovering co-leader to discuss how he or she controls
    thoughts and emotions.

-   Ask clients what connections they can make between thoughts and
    behavior and between emotions and behavior.

-   Remind clients of the importance of scheduling. Planning time
    thoroughly is one way of gaining control of behavior. Attending
    12-Step or mutual-help meetings, finding new activities, and
    resuming old hobbies also are good ways of steering behavior in
    productive directions.

2.  *Discussing the Importance of Recognizing Early Movement Toward
    Addictive Behaviors*

People who abuse substances often feel that their behavior is out of
their control because they experience uncontrollable urges to use
substances. By breaking down a behavior into the steps that precede it,
clients are able to control how they respond to urges. In session 1,
clients learned about thought-stopping techniques (handout ERS 1C) that
can interrupt the sequence of events that leads to craving and then to
using substances. Another way to prevent the reemergence of addictive
behaviors is for clients to recognize the early warning signs of
substance abuse: behaviors that clients know are linked to substance
abuse for them. Clients cannot maintain a successful recovery from
substance abuse if they continue to engage in the behaviors that
accompanied substance abuse.

-   Go over handout ERS 7B---Addictive Behavior.

-   Ask clients to assess honestly which behaviors from the list on the
    handout are related to their substance abuse.

-   Ask clients what behaviors that place them at risk for relapse are
    not listed.

-   Ask clients to think about how they can monitor their behavior
    (e.g., regular 12-Step attendance, keeping a diary, staying in touch
    with their sponsors).

-   Ask clients what they will do to avoid returning to substance use if
    they recognize that they have slipped into one of these addictive
    behaviors.

-   Ask the recovering co-leader to share experiences with addictive
    behaviors and how he or she avoided relapsing to substance use.

-   Ask the recovering co-leader to describe the benefits of being
    vigilant about addictive behaviors.

## *Scheduling (5 minutes)*

The counselor should remind clients that scheduling their time
rigorously and sticking to the schedule are part of the recovery
process. People who abuse substances are not accountable to schedules;
taking responsibility for sticking to a schedule helps clients stop
using. Following through on decisions made during scheduling helps keep
clients' rational brains in charge of behavior.

-   Ask clients how the schedule they made at the end of the previous
    session helped them remain drug free.

-   Ask clients what they learned about scheduling that will affect how
    they make future schedules.

-   Have clients complete handout SCH 2---Daily/Hourly Schedule for the
    time between this session and session 8.

#### ***Homework (5 minutes)***

Ask clients to share briefly their experience of doing the homework from
the previous session. The counselor can decide how detailed the followup
on homework should be. The goal of asking is not to discover which
clients have not done the homework but to encourage clients to work on
their recovery between sessions and to share that work with the group.

Have clients use pages 10 and 11 in their *Client's Treatment Companion*
to list a feeling that is linked with substance use, then list three
ways of coping with that feeling that do not involve substance use.

# **Session 8: 12-Step Wisdom**

## *Goals of Session*

-   Help clients identify 12-Step sayings that are helpful in recovery.

-   Help clients identify situations in which 12-Step sayings are
    helpful.

-   Help clients understand that people are more vulnerable to relapse
    when they are hungry, angry, lonely, or tired.

### *Handouts*

-   CAL 2---Calendar

-   ERS 8---12-Step Sayings

-   SCH 2---Daily/Hourly Schedule

## *Marking Progress (5 minutes)*

Before introducing the session topics, the counselor gives clients time
to chart their progress on CAL 2---Calendar and encourages clients to
share positive events they have experienced since the last session.

### *Topics for Group Discussion (35 minutes)*

1.  *Discussing the Usefulness of 12-Step Sayings*

> Many sayings that originated in Alcoholics Anonymous and became part
> of other 12-Step programs have taken root in popular discourse, too.
> Such phrases as "One day at a time" and "Keep it simple" may be
> familiar even to clients who have not participated in a 12-Step
> program. Because the phrases are familiar, clients may take them for
> granted. The counselor should present these sayings in the context of
> 12-Step programs so that clients can understand their value. The
> direct approach to recovery that these sayings convey can be used to
> support the usefulness of 12-Step participation.

-   Go over handout ERS 8---12-Step Sayings (up to discussion of the
    HALT acronym).

-   Ask clients which 12-Step sayings they find useful. Why?

-   Ask clients to imagine situations in which they would call on these
    phrases for strength or encouragement.

-   Ask the recovering co-leader to discuss what 12-Step wisdom means
    and how it has helped him or her in recovery.

2.  *Using 12-Step Wisdom To Avoid Relapse*

The counselor explains the acronym, HALT. Clients who have participated
in 12-Step programs before will be familiar with it and should be called
on to help explain its importance. Recovery is a process of returning
the body to a normal, healthy state. Controlling *hunger* by eating
regularly is an important part of recovery. *Anger* is a frequent cause
of relapse; it can drag clients down, making them feel bitter and
resentful. It is important for clients to learn how to recognize and
control anger. *Loneliness* is a common experience for clients in
recovery; clients may feel isolated from friends and loved ones. The
supportive fellowship of others in recovery helps combat loneliness.
Feeling *tired* is often a warning sign of a relapse. Along with eating
well, regular exercise and rest mitigate fatigue.

-   Go over the HALT acronym presented in handout ERS 8---12-Step
    Sayings.

-   Ask clients to share their answers to the questions at the end of
    the handout.

-   Ask clients which of the HALT states poses the greatest relapse risk
    for them. What strategies will help them avoid the relapse pitfalls
    mentioned in HALT?

-   Ask clients what other relapse risks exist for them. List these and
    perhaps make an acronym that represents them.

-   Ask the recovering co-leader to explain how HALT has helped him or
    her avoid relapse.

3.  *Offering an Alternative Approach*

The counselor should research local options to 12-Step programs and
expose clients to other types of recovery support in addition to 12-Step
programs. Many clients find help from the organizations listed on pages
44 and 45.

## *Scheduling (5 minutes)*

The counselor should remind clients that scheduling their time
rigorously and sticking to the schedule are part of the recovery
process. People who abuse substances are not accountable to schedules;
taking responsibility for sticking to a schedule helps clients stop
using. Following through on decisions made during scheduling helps keep
clients' rational brains in charge of behavior.

-   Ask clients how the schedule they made at the end of the previous
    session helped them remain drug free.

-   Ask clients what they learned about scheduling that will affect how
    they make future schedules.

-   Have clients complete handout SCH 2---Daily/Hourly Schedule for the
    time between this session and their next treatment group session.

#### ***Homework (5 minutes)***

Ask clients to share briefly their experience of doing the homework from
the previous session. The counselor can decide how detailed the followup
on homework should be. The goal of asking is not to discover which
clients have not done the homework but to encourage clients to work on
their recovery between sessions and to share that work with the group.

This is the final session of the Early Recovery Skills portion of
treatment. Have clients take some time to reflect on what they have
learned. Encourage them to write on pages 10 and 11 of their *Client's
Treatment Companion* and describe how they will use the skills they have
learned to help them in their recovery.

**Handouts for Early Recovery Skills Group Sessions**

The handouts that follow are to be used by clients with the counselor's
guidance. The handouts will help clients make the most of the eight ERS
sessions.

**SCH 1---The Importance of Scheduling**

Scheduling may be a difficult and boring task if you're not used to it.
It is, however, an important part of the recovery process. People with
substance use disorders do not schedule their time. Scheduling your time
will help you achieve and maintain abstinence.

1.  **Why Is Scheduling Necessary?**

If you began your recovery in a hospital, you would have the structure
of the program and the building to help you stop using. As a person in
outpatient treatment, you have to build that structure to help support
you as you continue functioning in the world. Your schedule is your
structure.

2.  **Do I Need To Write Down My Schedule?**

Absolutely. Schedules that are in your head are too easily revised. If
you write down your schedule while your rational brain is in control and
then follow the schedule, you will be doing what you *think* you should
be doing instead of what you *feel like* doing.

3.  **What if I Am Not an Organized Person?**

Learn to be organized. Buy a schedule book and work with your counselor.
Thorough scheduling of your activities is very important to treating
your substance use disorder. Remember, your rational brain plans the
schedule. If you follow the schedule, you won't use. Your addicted brain
wants to be out of control. If you go off the schedule, your addicted
brain may be taking you back to using drugs or drinking.

4.  **Who Decides What I Schedule?**

You do! You may consider suggestions made by your counselor or family
members, but the final decision is yours. Just be sure you do what you
wrote down. Follow your schedule; try not to make any changes.

Most people can schedule a 24-hour period and follow it. If you can, you
are on your way to gaining control of your life. If you cannot, you may
need to consider a higher level of care as a start.

**SCH 2---Daily/Hourly Schedule**

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

12:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

12:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

12:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11:00 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How many hours will you sleep? \_\_\_\_\_\_\_\_\_\_\_\_ From
\_\_\_\_\_\_\_\_\_\_\_\_\_\_ To \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Notes:**

**Reminders:**

**CAL 1---Marking Progress**

It is useful for both you and your counselor to know where you are in
the recovery process at all times. Marking a calendar as you go helps in
several ways:

-   It's a reminder of how far you've come in your recovery.

-   A feeling of pride often results from seeing the number of days you
    have been abstinent.

-   Recovery can seem very long unless you can measure your progress in
    short units of time.

Make a mark to record on the calendar pages every day of abstinence you
achieve. You may decide to continue the exercise following the program.

If you record your abstinent days regularly, this simple procedure will
help you and your counselor see your progress.

**CAL 2---Calendar**

**MONTH:**

  ------------ ------------ ------------- --------------- -------------- ------------ --------------
  **SUNDAY**   **MONDAY**   **TUESDAY**   **WEDNESDAY**   **THURSDAY**   **FRIDAY**   **SATURDAY**

                                                                                      

                                                                                      

                                                                                      

                                                                                      

                                                                                      
  ------------ ------------ ------------- --------------- -------------- ------------ --------------

####### ERS 1A---Triggers

Triggers are people, places, objects, feelings, and times that cause
cravings. For example, if every Friday night someone cashes a paycheck,
goes out with friends, and uses stimulants, the triggers might be

-   Friday night

-   After work

-   Money

-   Friends who use

-   A bar or club

Your brain associates the triggers with substance use. As a result of
constant triggering and using, one trigger can cause you to move toward
substance use. The trigger--thought--craving--use cycle feels
overwhelming.

Stopping the craving process is an important part of treatment. The best
way to do that is to do the following:

1\. Identify triggers.

2\. Prevent exposure to triggers whenever possible (for example, do not
handle large amounts of cash).

3\. Cope with triggers differently than in the past (for example,
schedule exercise and a 12-Step or mutual-help meeting for Friday
nights).

Remember, triggers affect your brain and cause cravings even though you
have decided to stop substance use. Your intentions to stop must
translate into behavior changes, which keep you away from possible
triggers.

**What are some of the strongest triggers for you?**

**What particular triggers might be a problem in the near future?**

### ERS 1B---Trigger--Thought--Craving--Use

######## The Losing Argument

If you decide to stop drinking or using but at some point end up moving
toward using substances, your brain has given you permission by using a
process called relapse justification. Thoughts about using start an
argument inside your head---your rational self versus your
substance-dependent self. You feel as though you are in a fight, and you
must come up with many reasons to stay abstinent. Your mind is looking
for an excuse to use again. You are looking for a relapse justification.
The argument inside you is part of a series of events leading to
substance use. How often in the past has your substance dependence lost
this argument?

######## Thoughts Become Cravings

Craving does not always occur in a straightforward, easily recognized
form. Often the thought of using passes through your head with little or
no effect. But it's important to identify these thoughts and try to
eliminate them. It takes effort to identify and stop a thought. However,
allowing yourself to continue thinking about substance use is choosing
to relapse. The further the thoughts are allowed to go, the more likely
you are to relapse.

######## The "Automatic" Process

During addiction, triggers, thoughts, cravings, and use seem to run
together. However, the usual sequence goes like this:

**TRIGGER → THOUGHT →** **CRAVING → USE**

######## Thought Stopping

The only way to ensure that a thought won't lead to a relapse is to stop
the thought before it leads to craving. Stopping the thought when it
first begins prevents it from building into an overpowering craving. It
is important to do it as soon as you realize you are thinking about
using.

**ERS 1C---Thought-Stopping Techniques**

######## A New Sequence

To start recovery, it is necessary to interrupt the
trigger--thought--craving--use sequence. Thought stopping provides a
tool for disrupting the process.

Thought-stopping

techniques

Trigger Thought

Continued Cravings Use

thoughts

This process is not automatic. You make a choice either to continue
thinking about using (and start on the path toward relapse) or to stop
those thoughts.

######## Thought-Stopping Techniques

Try the techniques described below, and use those that work best for
you:

-   **Visualization.** Imagine a scene in which you deny the power of
    thoughts of use. For example, picture a switch or a lever in your
    mind. Imagine yourself actually moving it from ON to OFF to stop the
    using thoughts. Have another picture ready to think about in place
    of those thoughts.

-   **Snapping.** Wear a rubberband loosely on your wrist. Each time you
    become aware of thoughts of using, snap the rubberband and say,
    "No!" to the thoughts as you make yourself think about another
    subject. Have a subject ready that is meaningful and interesting to
    you.

-   **Relaxation.** Feelings of hollowness, heaviness, and cramping in
    the stomach are cravings. These often can be relieved by breathing
    in deeply (filling lungs with air) and breathing out slowly. Do this
    three times. You should be able to feel the tightness leaving your
    body. Repeat this whenever the feeling returns.

-   **Call someone.** Talking to another person provides an outlet for
    your feelings and allows you to hear your thinking process. Have
    phone numbers of supportive, available people with you always, so
    you can use them when you need them.

+-----------------------------------------------------------------------+
| **ALLOWING THE THOUGHTS TO DEVELOP INTO**                             |
|                                                                       |
| **CRAVINGS IS MAKING A CHOICE TO REMAIN DEPENDENT ON SUBSTANCES.**    |
+-----------------------------------------------------------------------+

**ERS 2A---External Trigger Questionnaire**

**Place a checkmark next to activities, situations, or settings in which
you frequently used substances; place a zero next to activities,
situations, or settings in which you never have used substances.**

\_\_\_\_ **Home alone** \_\_\_\_ **Before a date** \_\_\_\_ **After
payday**

\_\_\_\_ **Home with friends** \_\_\_\_ **During a date** \_\_\_\_
**Before going out to dinner**

\_\_\_\_ **Friend's home** \_\_\_\_ **Before sexual activities**
\_\_\_\_ **Before breakfast**

\_\_\_\_ **Parties** \_\_\_\_ **During sexual activities** \_\_\_\_ **At
lunch break**

\_\_\_\_ **Sporting events** \_\_\_\_ **After sexual activities**
\_\_\_\_ **While at dinner**

\_\_\_\_ **Movies** \_\_\_\_ **Before work** \_\_\_\_ **After work**

\_\_\_\_ **Bars/clubs** \_\_\_\_ **When carrying mone**y \_\_\_\_
**After passing a particular**

\_\_\_\_ **Beach** \_\_\_\_ **After going past dealer's** **street or
exit**

\_\_\_\_ **Concerts** **residence** \_\_\_\_ **School**

\_\_\_\_ **With friends who** \_\_\_\_ **Driving** \_\_\_\_ **The park**

**use drugs** \_\_\_\_ **Liquor store** \_\_\_\_ **In the neighborhood**

\_\_\_\_ **When gaining weight** \_\_\_\_ **During work**
\_\_\_\_**Weekends**

\_\_\_\_ **Vacations/holidays** \_\_\_\_ **Talking on the phone**
\_\_\_\_**With family members**

\_\_\_\_ **When it's raining** \_\_\_\_ **Recovery groups**
\_\_\_\_**When in pain**

**List any other activities, situations, or settings where you
frequently have used.**

**List activities, situations, or settings in which you would not use.**

**List people you could be with and not use.**

**ERS 2B---External Trigger Chart**

Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Instructions:** List people, places, objects, or situations below
according to their degree of association with substance use.

0% 100%

Chance of Using Chance of Using

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Never Use Almost Never Use Almost Always Use Always Use

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

These situations are "safe." These situations are low risk, These
situations are high Involvement in but caution is needed. risk. Staying
in these is these situations

extremely dangerous. is deciding

to stay addicted.

Avoid totally.

### ERS 3A---Internal Trigger Questionnaire

During recovery certain feelings or emotions often trigger the brain to
think about using substances. **Read the following list of feelings and
emotions, and place a checkmark next to those that might trigger
thoughts of using for you. Place a zero next to those that are not
connected with using.**

\_\_\_\_\_ **Afraid** \_\_\_\_\_ **Frustrated** \_\_\_\_\_ **Neglected**

\_\_\_\_\_ **Angry** \_\_\_\_\_ **Guilty** \_\_\_\_\_ **Nervous**

\_\_\_\_\_ **Confident** \_\_\_\_\_ **Happy** \_\_\_\_\_ **Passionate**

\_\_\_\_\_ **Criticized** \_\_\_\_\_ **Inadequate** \_\_\_\_\_
**Pressured**

\_\_\_\_\_ **Depressed** \_\_\_\_\_ **Insecure** \_\_\_\_\_ **Relaxed**

\_\_\_\_\_ **Embarrassed** \_\_\_\_\_ **Irritated** \_\_\_\_\_ **Sad**

\_\_\_\_\_ **Excited** \_\_\_\_\_ **Jealous** \_\_\_\_\_ **Bored**

\_\_\_\_\_ **Exhausted** \_\_\_\_\_ **Lonely** \_\_\_\_\_ **Envious**

\_\_\_\_\_ **Deprived** \_\_\_\_\_ **Humiliated** \_\_\_\_\_ **Anxious**

\_\_\_\_\_ **Aroused** \_\_\_\_\_ **Revengeful** \_\_\_\_\_ **Worried**

\_\_\_\_\_ **Grieving** \_\_\_\_\_ **Resentful** \_\_\_\_\_
**Overwhelmed**

\_\_\_\_\_ **Misunderstood** \_\_\_\_\_ **Paranoid** \_\_\_\_\_
**Hungry**

**What emotional states that are not listed above have triggered you to
use substances?**

**Was your use in the weeks before entering treatment**

\_\_\_\_\_ **Tied primarily to emotional conditions?**

\_\_\_\_\_ **Routine and automatic without much emotional triggering?**

**Were there times in the recent past when you were not using and a
specific change in your mood clearly resulted in your wanting to use
(for example, you got in a fight with someone and wanted to use in
response to getting angry)?** Yes \_\_\_\_\_ No \_\_\_\_\_

**If yes, describe:**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**ERS 3B---Internal Trigger Chart**

Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Instructions:** List emotional states below according to their degree
of association with substance use.

0% 100%

Chance of Using Chance of Using

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Never Use Almost Never Use Almost Always Use Always Use

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

These emotions are "safe." These emotions are low risk, These emotions
are high Persisting in these

but caution is needed. risk. emotions is deciding to stay

addicted. Avoid totally.

**ERS 4A---12-Step Introduction**

**Meetings**

***What Is a 12-Step Program?***

In the 1930s, Alcoholics Anonymous (AA) was founded by two men who could
not cope with their own alcoholism through psychiatry or medicine. They
found a number of specific principles helped people overcome their
alcohol dependence. They formed AA to introduce people who were
dependent on alcohol to these self-help principles. The AA concepts have
been adapted to stimulant and other drug addictions (for example,
Crystal Meth Anonymous, Narcotics Anonymous \[NA\], and Cocaine
Anonymous) and to compulsive behaviors such as gambling and overeating.

People dependent on drugs or alcohol have found that others who also are
dependent can provide enormous support and help to one another. For this
reason, these groups are called fellowships, where participants show
concern and support for one another through sharing and understanding.

***Do I Need To Attend 12-Step Meetings?***

If treatment in this program is going to work for you, it is essential
to establish a network of support for your recovery. Attending treatment
sessions without going to 12-Step meetings may produce a temporary
effect. But without involvement in self-help programs, it is very
unlikely that you will successfully recover. Clients in these programs
should attend three 12-Step meetings per week during their treatment
involvement. Many successfully abstinent people go to 90 meetings in 90
days. The more you participate in treatment and 12-Step meetings, the
greater your chance for recovery.

***Are All Meetings the Same?***

No. There are different types of meetings:

-   Speaker meetings feature a person in recovery telling his or her
    story of drug and alcohol use and recovery.

-   Topic meetings have a discussion on a specific topic such as
    fellowship, honesty, acceptance, or patience. Everyone is given a
    chance to talk, but no one is forced.

-   Step/Tradition meetings are special meetings where the 12 Steps and
    12 Traditions are discussed.

-   Book study meetings focus on reading a chapter from the main text of
    the 12-Step group. (For AA, this is the Big Book; for NA, the Basic
    Text.) Book study meetings often focus on someone's experience or a
    recovery-related topic.

-   Depending on where you live, there may be language-specific
    meetings, gender-specific meetings, open meetings, meetings based on
    participants' sexual orientation, and meetings for people who also
    have a mental disorder ("double trouble" Dual Recovery Anonymous
    meetings).

***Are the 12-Step Programs Religious?***

No. None of the 12-Step programs are religious, but spiritual growth is
considered a part of recovery. Spiritual choices are very personal and
individual. Each person decides for himself or herself what the term
"higher power" means. Both nonreligious and religious people can find
value and support in 12-Step programs.

***How Do I Find a Meeting?***

You can call directory assistance or check the phonebook for Alcoholics
Anonymous, Cocaine Anonymous, or Narcotics Anonymous. Listings for
Crystal Meth Anonymous meetings can be found at www.crystalmeth.org. You
can call the numbers available from the Web site and speak to someone
who can tell you when and where meetings are scheduled. At meetings,
directories are available that list meetings by city, street address,
and meeting time and include information about the meeting (for example,
speaker, step study, nonsmoking, men's, or women's). Another way to find
a good meeting is to ask someone who goes to 12-Step meetings.

**Sponsors**

The first few weeks and months of recovery are frustrating. Many things
happen that are confusing and frightening. During this difficult period,
there are many times when people in recovery need to talk about problems
and fears. A sponsor helps guide a newcomer through this process.

***What Do Sponsors Do?***

-   Sponsors help the newcomer by answering questions and explaining the
    12-Step recovery process.

-   Sponsors agree to be available to listen to their sponsorees'
    difficulties and frustrations and to share their insights and
    solutions.

-   Sponsors provide guidance and help address problems their sponsorees
    are having. This advice comes from their personal experiences with
    long-term abstinence.

-   Sponsors are people with whom addiction-related secrets and guilt
    feelings can be shared easily. They agree to keep these secrets
    confidential and to protect the newcomer's anonymity.

-   Sponsors warn their sponsorees when they get off the path of
    recovery. Sponsors often are the first people to know when their
    sponsorees experience a slip or relapse. So, sponsors often push
    their sponsorees to attend more meetings or get help for problems.

-   Sponsors help their sponsorees work through the 12 Steps.

######## *How Do I Pick a Sponsor?*

The process of choosing a sponsor is easy. The newcomer simply asks
someone to be his or her sponsor. But you need to think carefully about
whom you will ask to sponsor you. Most people select a sponsor who seems
to be living a healthy and responsible life, the kind of life a person
in recovery would want to lead.

Some general guidelines for selecting a sponsor include the following:

-   A sponsor should have several years of abstinence from all
    mood-altering drugs.

-   A sponsor should have a healthful lifestyle and not be struggling
    with major problems or addiction.

-   A sponsor should be an active and regular participant in 12-Step
    meetings. Also, a sponsor should be someone who actively "works" the
    12 Steps.

-   A sponsor should be someone to whom you can relate. You may not
    always agree with your sponsor, but you need to be able to respect
    your sponsor.

-   A sponsor should be someone you would not become romantically
    interested in.

######### 

######### Alternatives to 12-Step Programs

There are alternatives to 12-Step groups, many of which are not based on
the concept of a higher power. Although the philosophies of these groups
differ, most offer a mutual-help approach that focuses on personal
responsibility, personal empowerment, and strength through an abstinent
social network. Here are a few notable alternatives to 12-Step groups:

-   Women for Sobriety (www.womenforsobriety.org) helps women overcome
    alcohol dependence through emotional and spiritual growth.

-   Jewish Alcoholics, Chemically Dependent Persons and Significant
    Others (JACS) (www.jacsweb.org) helps people explore recovery in a
    nurturing Jewish environment.

-   Self-Management and Recovery Training (SMART)
    (www.smartrecovery.org) is a cognitive--behavioral group approach
    that focuses on self-reliance, problemsolving, coping strategies,
    and a balanced lifestyle.

-   Secular Organizations for Sobriety (www.secularhumanism.org)
    maintains that sobriety is a separate issue from religion or
    spirituality and credits the individual for achieving and
    maintaining sobriety.

-   Community-based spiritual fellowships, which take place in churches,
    synagogues, mosques, temples, and other spiritually focused
    settings, often help people clarify their values and change their
    lives.

######## Questions To Consider

-   Have you ever been to a 12-Step meeting? If so, what was your
    experience?

-   Have you attended any other types of recovery meetings (such as
    those listed above)?

-   Do you plan to attend any 12-Step meetings? Where? When?

-   How might you make use of 12-Step meetings to stop using?

-   Are there alternatives to 12-Step meetings that you might consider
    attending?

> **ERS 4B---The Serenity Prayer and the**
>
> **12 Steps of Alcoholics Anonymous**

######## The Serenity Prayer

God grant me the serenity to accept the things I cannot change, the
courage to change the things I can, and the wisdom to know the
difference.

######## The 12 Steps of Alcoholics Anonymous[^1]

1.  We admitted that we were powerless over alcohol---that our lives had
    become unmanageable.

2.  Came to believe that a Power greater than ourselves could restore us
    to sanity.

3.  Made a decision to turn our will and our lives over to the care of
    God as we understood Him.

4.  Made a searching and fearless moral inventory of ourselves.

5.  Admitted to God, to ourselves, and to another human being the exact
    nature of our wrongs.

6.  Were entirely ready to have God remove all these defects of
    character.

7.  Humbly asked Him to remove our shortcomings.

8.  Made a list of all persons we had harmed and became willing to make
    amends to them all.

9.  Made direct amends to such people wherever possible, except when to
    do so would injure them or others.

10. Continued to take personal inventory, and when we were wrong,
    promptly admitted it.

11. Sought through prayer and meditation to improve our conscious
    contact with God as we understood Him, praying only for knowledge of
    His will for us and the power to carry that out.

12. Having had a spiritual awakening as a result of the steps, we tried
    to carry this message to alcoholics and to practice these principles
    in all our affairs.

**ERS 5---Roadmap for Recovery**

Recovery from a substance use disorder is not a mysterious process.
After the use of substances is stopped, the brain goes through a
biological readjustment. This readjustment process is essentially a
"healing" of the chemical changes that were produced in the brain by
substance use. It is important for people in the beginning stages of
recovery to understand why they may experience some physical and
emotional difficulties. The durations of the stages listed below are a
rough guide of recovery, not a schedule. The length of stages will vary
from person to person. The substance used will affect the client's
progress through the stages, too. Clients who had been using
methamphetamine will tend to spend more time in each stage than clients
who were using cocaine or other stimulants.

######### The Stages

***Withdrawal Stage (1 to 2 weeks)***

During the first days after substance use is stopped, some people
experience difficult symptoms. The extent of the symptoms often is
related to the amount, frequency, and type of their previous substance
use.

For people who use stimulants, withdrawal can be accompanied by drug
craving, depression, low energy, difficulty sleeping or excessive sleep,
increased appetite, and difficulty concentrating. Although people who
use stimulants do not experience the same degree of physical symptoms as
do people who use alcohol, the psychological symptoms of craving and
depression can be quite severe. Clients may have trouble coping with
stress and may be irritable.

People who drank alcohol in large amounts may have the most severe
symptoms. The symptoms can include nausea, low energy, anxiety,
shakiness, depression, intense emotions, insomnia, irritability,
difficulty concentrating, and memory problems. These symptoms typically
last 3 to 5 days but can last up to several weeks. Some people must be
hospitalized to detox safely.

For people who used opioids or prescription drugs, the 7- to 10-day
withdrawal period (or longer for people who use benzodiazepines) can be
physically uncomfortable and may require hospitalization and medication.
It is essential to have a physician closely monitor withdrawal in people
dependent on these substances. Along with the physical discomfort, many
people experience nervousness, trouble sleeping, depression, and
difficulty concentrating. Successfully completing withdrawal from these
substances is a major achievement in early recovery.

######## *Early Abstinence (4 weeks; follows Withdrawal)*

For people who used stimulants, this 4-week period is called the
Honeymoon. Most people feel quite good during this period and often feel
"cured." As a result, clients may want to drop out of treatment or stop
attending 12-Step meetings during the Honeymoon period. Early abstinence
should be used as an opportunity to establish a good foundation for
recovery. If clients can direct the energy, enthusiasm, and optimism
felt during this period into recovery activities, they can lay the
foundation for future success.

For people who used alcohol, this 4-week period is marked by the brain's
recovery. Although the physical withdrawal symptoms have ended, clients
still are getting used to the absence of substances. Thinking may be
unclear, concentration may be poor, nervousness and anxiety may be
troubling, sleep is often irregular, and, in many ways, life feels too
intense.

For those who used opioids or prescription drugs, there is essentially a
gradual normalization during this period. In many ways the process is
similar to the alcohol recovery timetable. Slow, gradual improvement in
symptoms is evidence that the recovery is progressing.

######## *Protracted Abstinence (3.5 months; follows Early Abstinence)*

From 6 weeks to 5 months after clients stop using, they may experience a
variety of annoying and troublesome symptoms. These
symptoms---difficulties with thoughts and feelings---are caused by the
continuing healing process in the brain. This period is called the Wall.
It is important for clients to be aware that some of the feelings during
this period are the result of changes in brain chemistry. If clients
remain abstinent, the feelings will pass. The most common symptoms are
depression, irritability, difficulty concentrating, low energy, and a
general lack of enthusiasm. Clients also may experience strong cravings
during protracted abstinence. Relapse risk goes up during this period.
Clients must stay focused on remaining abstinent one day at a time.
Exercise helps tremendously during this period. For most clients,
completing this phase in recovery is a major achievement.

***Readjustment (2 months; follows Protracted Abstinence)***

After 5 months, the brain has recovered substantially. Now, the client's
main task is developing a life that has fulfilling activities that
support continued recovery. Although a difficult part of recovery is
over, hard work is needed to improve the quality of life. Because
cravings occur less often and feel less intense 6 months into recovery,
clients may be less aware of relapse risk and put themselves in
high-risk situations and increase their relapse risk.

**ERS 6A---Five Common Challenges in Early Recovery**

Everyone who attempts to stop using substances runs into situations that
make it difficult to maintain abstinence. Listed below are five of the
most common situations that are encountered during the first few weeks
of treatment. Next to these problems are some suggested alternatives for
handling these situations.

+-----------------------+----------------------------------------------+
| **Challenges**        | **New Approaches**                           |
+=======================+==============================================+
| Friends and           | -   Try to make new friends at 12-Step or    |
| associates who use:   |     mutual-help meetings.                    |
| You want to continue  |                                              |
| associations with old | -   Participate in new activities or hobbies |
| friends or friends    |     that will increase your chances of       |
| who use.              |     meeting abstinent people.                |
|                       |                                              |
|                       | -   Plan activities with abstinent friends   |
|                       |     or family members.                       |
+-----------------------+----------------------------------------------+
| Anger, irritability:  | -   Remind yourself that recovery involves a |
| Small events can      |     healing of brain chemistry. Strong,      |
| create feelings of    |     unpredictable emotions are a natural     |
| anger that seem to    |     part of recovery.                        |
| preoccupy your        |                                              |
| thoughts and can lead | -   Engage in exercise.                      |
| to relapse.           |                                              |
|                       | -   Talk to a counselor or a supportive      |
|                       |     friend.                                  |
+-----------------------+----------------------------------------------+
| Substances in the     | -   Get rid of all drugs and alcohol.        |
| home: You have        |                                              |
| decided to stop       | -   Ask others to refrain from using and     |
| using, but others in  |     drinking at home.                        |
| your house may still  |                                              |
| be using.             | -   If you continue to have a problem, think |
|                       |     about moving out for a while.            |
+-----------------------+----------------------------------------------+
| Boredom, loneliness:  | -   Put new activities in your schedule.     |
| Stopping substance    |                                              |
| use often means that  | -   Go back to activities you enjoyed before |
| activities you did    |     your addiction took over.                |
| for fun and the       |                                              |
| people with whom you  | -   Develop new friends at 12-Step or        |
| did them must be      |     mutual-help meetings.                    |
| avoided.              |                                              |
+-----------------------+----------------------------------------------+
| Special occasions:    | -   Have a plan for answering questions      |
| Parties, dinners,     |     about not using substances.              |
| business meetings,    |                                              |
| and holidays without  | -   Start your own abstinent celebrations    |
| substance use can be  |     and traditions.                          |
| difficult.            |                                              |
|                       | -   Have your own transportation to and from |
|                       |     events.                                  |
|                       |                                              |
|                       | -   Leave if you get uncomfortable or start  |
|                       |     feeling deprived.                        |
+-----------------------+----------------------------------------------+

######## Are some of these issues likely to be problems for you in the next few weeks? Which ones? 

**How will you handle them?**

**ERS 6B---Alcohol Arguments**

Have you been able to stop using alcohol completely? At about 6 weeks
into the recovery process, many people return to alcohol use. Has your
addicted brain played with the idea? These are some of the most common
arguments against stopping the use of alcohol and answers to the
arguments.

**I came here to stop using speed, not to stop drinking.**

Part of stopping methamphetamine use is stopping all substance use,
including alcohol use.

**I've had drinks and not used, so it doesn't make any difference.**

Drinking over time greatly increases the risk of relapse. A single drink
does not necessarily cause relapse anymore than a single cigarette
causes lung cancer. However, with continued drinking, the risks of
relapse greatly increase.

**Drinking actually helps. When I have a craving, a drink calms me down,
and the craving goes away.**

Alcohol interferes with the brain's chemical healing process. Continued
alcohol use eventually intensifies cravings, even if one drink seems to
reduce cravings.

**I'm not an alcoholic, so why do I need to stop drinking.**

If you're not an alcoholic, you should have no problem stopping alcohol
use. If you can't stop, maybe alcohol is more of a problem than you
realize.

**I'm never going to use drugs again, but I'm not sure I'll never drink
again.**

Make a 6-month commitment to total abstinence. Give yourself the chance
to make a decision about alcohol with a drug-free brain. If you reject
alcohol abstinence because "forever" scares you, then you're justifying
drinking now and risking relapse to substance use.

**Has your addicted brain presented you with other justifications? If
so, what are they?**

**How are you planning to handle alcohol use in the future?**

**ERS 7A---Thoughts, Emotions, and Behavior**

Habitual substance use changes the way people think, how they feel, and
how they behave. How do these changes affect the recovery process?

######## Thoughts

Thoughts happen in the rational part of the brain. They are like
pictures on the TV screen of the mind. Thoughts can be controlled. As
you become aware of your thoughts, you can learn to change channels in
your brain. Learning to turn off thoughts of substance use is a very
important part of the recovery process. It is not easy to become aware
of your thinking and to learn to control the process. With practice it
gets easier.

######## Emotions

Emotions are feelings. Happiness, sadness, anger, and fear are some
basic emotions. Feelings are the mind's response to things that happen
to you. Feelings cannot be controlled; they are neither good nor bad. It
is important to be aware of your feelings. Talking to family members,
friends, or a counselor can help you recognize how you feel. People
normally feel a range of emotions. Drugs can change your emotions by
changing the way your brain works. During recovery, emotions are often
still mixed up. Sometimes you feel irritated for no reason or great even
though nothing wonderful has happened. You cannot control or choose your
feelings, but you can control what you do about them.

######## Behavior

What you do is behavior. Work is behavior. Play is behavior. Going to
treatment is behavior, and substance use is behavior. Behavior can
result from an emotion, from a thought, or from a combination of both.
Repeated use of a substance changes your thoughts and pushes your
emotions toward substance use. This powerful, automatic process has to
be brought back under control for recovery to occur. Structuring time,
attending 12-Step or mutual-help meetings, and engaging in new
activities are all ways of regaining control. The goal in recovery is to
learn to combine your thinking and feeling self and behave in ways that
are best for you and your life.

**ERS 7B---Addictive Behavior**

People who abuse substances often feel that their lives are out of
control. Maintaining control becomes harder and harder the longer they
have been abusing substances. People do desperate things to continue to
appear normal. These desperate behaviors are called addictive
behaviors---behaviors related to substance use. Sometimes these
addictive behaviors occur only when people are using or moving toward
using. Recognize when you begin to engage in these behaviors. That's
when you know to start fighting extra hard to move away from relapse.

**Which of these behaviors do you think are related to your drug or
alcohol use?**

**Lying**

**Stealing**

**Being irresponsible (for example, not meeting family or work
commitments)**

**Being unreliable (for example, being late for appointments, breaking
promises)**

**Being careless about health and grooming (for example, wearing "using"
clothes, avoiding exercise, eating poorly, having a messy appearance)**

**Getting sloppy in housekeeping**

**Behaving impulsively (without thinking)**

**Behaving compulsively (for example, too much eating, working, sex)**

**Changing work habits (for example, working more, less, not at all, new
job, change in hours)**

**Losing interest in things (for example, recreational activities,
family life)**

**Isolating (staying by yourself much of the time)**

**Missing or being late for treatment**

**Using other drugs or alcohol**

**Stopping prescribed medication (for example, disulfiram, naltrexone)**

**ERS 8---12-Step Sayings**

The program of Alcoholics Anonymous has developed some short sayings
that help people in their day-to-day efforts at staying sober. These
concepts are often useful tools in learning how to establish sobriety.

######## One day at a time

This is a key concept in staying abstinent. Don't obsess about staying
abstinent forever. Just focus on today.

######## Turn it over

Sometimes people with addictions jeopardize their recovery by tackling
problems that cannot be solved. Finding a way to let go of issues so
that you can focus on staying abstinent is a very important skill.

######## Keep it simple

Learning to stay abstinent can get complicated and seem overwhelming if
you let it. In fact, there are some simple concepts involved. Don't make
this process difficult: keep it simple.

######## Take what you need and leave the rest 

Not everyone benefits from every part of 12-Step meetings. It is not a
perfect program. However, if you focus on the parts you find useful,
rather than the ones that bother you, the program has something for you.

######## Bring your body, the mind will follow 

The most important aspect of 12-Step programs is attending the meetings.
It takes a while to feel completely comfortable. Try different meetings,
try to meet people, and read the materials. Just go and keep going.

**HALT**

This acronym is familiar to people in the 12-Step programs. It is a
shorthand way of reminding people in recovery that they are especially
vulnerable to relapse when they are too hungry, angry, lonely, or tired.

-   **H**ungry: When people are using, they often ignore their
    nutritional needs. People in recovery need to relearn the importance
    of eating regularly. Being hungry can cause changes in body
    chemistry that make people less able to control themselves or avoid
    cravings. Often the person feels anxious and upset but doesn't
    associate the feelings with hunger. Eating regularly increases
    emotional stability.

-   **A**ngry: This emotional state is probably the most common cause of
    relapse to drug use. Learning to cope with anger in a healthy way is
    difficult for many people. It is not healthy to act in anger without
    thinking about the consequences. Nor is it healthy to hold anger in
    and try to pretend it doesn't exist. Talking about anger-producing
    situations and how to handle them is an important part of recovery.

-   **L**onely: Recovery is often a lonely process. People lose
    relationships because of their substance use. As part of staying
    abstinent, people in recovery may have to give up friends who still
    use. The feelings of loneliness are real and painful. They make
    people more vulnerable to relapse.

-   **T**ired: Sleep disorders are often a part of early recovery.
    People in recovery frequently have to give up chemical aids to sleep
    that they used in the past. Being tired is often a trigger for
    relapse. Feeling exhausted and low on energy leaves people
    vulnerable and unable to function in a healthy way.

######## How often do you find yourself in one or more of these emotional states?

**What could you do differently to avoid being so vulnerable?**

[^1]: The Twelve Steps are reprinted with permission of Alcoholics
    Anonymous World Services, Inc. (A.A.W.S.). Permission to reprint the
    Twelve Steps does not mean that A.A.W.S. has reviewed or approved
    the contents of this publication, or that A.A.W.S. necessarily
    agrees with the views expressed herein. A.A. is a program of
    recovery from alcoholism *only*---use of the Twelve Steps in
    connection with programs and activities which are patterned after
    A.A., but which address other problems, or in any other non-A.A.
    context, does not imply otherwise.