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4 th – 5 th Step Workshop

4 th – 5 th Step Workshop. Greg Gable, PsyD Scott Teitelbaum , M.D., FASAM Ken Thompson, M.D. , FASAM. Ken Thompson. Introduction. Introduction. Relapse is associated with personality disorders in physicians Depth and power of 12 steps often underestimated by professionals

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4 th – 5 th Step Workshop

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  1. 4th – 5th Step Workshop Greg Gable, PsyD Scott Teitelbaum, M.D., FASAM Ken Thompson, M.D. , FASAM

  2. Ken Thompson Introduction

  3. Introduction • Relapse is associated with personality disorders in physicians • Depth and power of 12 steps often underestimated by professionals • 4th step gives clues to characterologic traits which are formative of personality styling • Relapse is associated with not doing a thorough 4th step by self report • 4th step is useful to process resentments, a known relapse trigger • Useful clinical information is gleaned from group 4th- 5th step work

  4. Greg Gable Relevant research & psychological observations

  5. Relevant Research • Risk factors for relapse included: • Family history of substance use disorder • Opiate use in the context of a comorbid psychiatric disorder • Comorbid psychiatric disorder (Largely on Axis I) Domino, Karen B. MD, MPH; Hornbein, Thomas F. MD; Polissar, Nayak L. PhD; Renner, Ginger; Johnson, Jilda; Alberti, Scott; Hankes, Lynn MD, 2005

  6. Relevant Research • Cohort of 292 subjects • 107 with comorbid diagnosis • 100 with comorbid Axis I diagnosis • 5 with comorbid Axis II diagnosis • 2 with both Domino, Karen B. MD, MPH; Hornbein, Thomas F. MD; Polissar, Nayak L. PhD; Renner, Ginger; Johnson, Jilda; Alberti, Scott; Hankes, Lynn MD, 2005

  7. Relevant Research • 60.3% of assessed physicians suffered from comorbid SUD and psychiatric disorders • 56.8% with Axis II disorder • 54.5% with Axis I mood disorders • 34.1% combined • 18.2% anxiety disorders Angres, McGovern, Rawal, Purva, & Shaw, 2002

  8. Relevant Research • Physicians with comorbid diagnoses: • Did as well in treatment as controls • Seemed to have equivalent treatment outcomes at follow up • Seemed to report greater degrees of emotional distress even when engaged in a stable recovery Angres, McGovern, Rawal, Purva, & Shaw, 2002

  9. Relevant Research • 308 physician cohort • 78 physicians with relapse (25%) • 230 physicians with no relapse (75%) • 78 physician relapse population • 55 physicians reengaged in monitored recovery • 92% of original cohort in monitored recovery of at least 5 years Gable 2002

  10. Relevant Research Time to First Relapse Year of relapse f % _____ • <1 11 22% • 1-5 25 48% • 5-10 10 20% • >10 4 8%_____ Gable 2002

  11. Drug of Choice Gable 2002

  12. Relapse Relevance Condition relapse non-relapse Abuse * 26 52% 22 45% Family SUD 30 61% 37 75% Eating Disorder 10 20% 11 21% Compulsive Behaviors 15 30% 11 21% _________________ * Emotional/Physical/Sexual Abuse Gable 2002

  13. Relapse Relevance • The presence of an Axis II disorder was strongly related to relapse • (χ² = 16.071, df = 1, p<.05) (46% of the relapse group had an Axis II diagnosis, compared to eight percent of the non-relapse group). (p actually computed as .000) Gable 2002

  14. Relapse Relevance Personality Disorder Diagnosis Diagnosis relapse non-relapse OCPD 4 8% 0 0% NPD 2 4% 0 0% BPD 2 4% 0 0% PD NOS 15 30% 4 8% Gable 2002

  15. Relapse Relevance • The presence of a comorbid Axis I diagnosis was significantly related to relapse • ( χ² = 9.180, df = 1, p<.05). (p computed to .002) Gable 2002

  16. Relapse relevance Axis I disorder relapse non-relapse Bipolar 6 12% 1 2% MDD 12 24% 7 14% Dysthymic 1 2% 2 4% Bulimia 3 6% 3 6% PTSD 1 2% 1 2% Anxiety/Panic 3 6% 0 0% OCD 1 2% 0 0% Sexual 1 2% 0 0% ADHD 1 2% 0 0% (43% of overall sample had a comorbid Axis I dx) Gable 2002

  17. Relapse Relapse • When the presence of an Axis II disorder is combined with the presence of an secondary Axis I disorder (not including secondary substance use disorder diagnoses), the presence of a co-occurring psychiatric disorder on Axis I or Axis II was strongly related to relapse • (χ² = 23.645, df=1, p<.05). (p actually computed to .000) Gable 2002

  18. Relapse Relevance Relapse Status f % of group Relapse 41 82% No Relapse 17 34% Note: Comorbid secondary substance use disorders are not included Gable 2002

  19. Project Match Data • Compared CBT, MET, and TSF • Months 4 to 15 Sobriety • CBT = 15% • MET = 14% • TSF = 24% • The advantage of TSF endured through the 12 month follow up period (NIAAA)

  20. Personality/Relational Issues as Relapse Factor • Presence of relational difficulties presents barriers to effective long-term use of tools • Traits increase relapse risk because: • Less assiduous use of tools • Pt. can revert to pre-recovery coping mechanisms at times of heightened emotional stimulation (positive or negative) • Learned use of tools over time can decay

  21. Diagnostic Issues • Danger in diagnosing personality disorder too early in treatment process • Danger in diverting patient focus from addiction to “psychological issues” • Tendency to postpone addressing of these issues in favor of recovery tools/comparing in.

  22. Implications for Treatment/Recovery • Trauma often a factor • Important to help patient identify the trauma and importance for working with it over time • Important not to avoid trauma material in treatment • Unresolved/undisclosed trauma can prevent honest sharing with others

  23. Case Study Sarah • Internist • Treated in long-term residential • Relapsed soon after to meds not covered on HP panel (after researching this) • Flew under radar for over a year, then relapse became visible • Returned to long-term residential treatment • Personality issues, cluster B a problem in treatment

  24. Case Study Sarah • Discharged early because of rule violations • Struggled in outpatient, willful, not accepting of treatment plan • About 8 months after second tx experience, began to show changes • When interviewed, identified sponsor and 4th step as change agent

  25. Case Study Sarah • Mary identified a character defect as having been central to her difficulty in recovery • When asked to name this defect, she did not describe narcissistic, borderline or antisocial traits. • She talked about becoming aware of her intolerance, lack of acceptance • This construct was, for her, something to build change upon.

  26. Project Match Data -Compared CBT, MET, and TSF -Months 4 to 15 Sobriety CBT = 15% MET = 14% TSF = 24%The advantage of TSF endured through the 12 month follow up period (NIAAA)

  27. What we have learned • Important to bring the traits into awareness • Important to make work on the traits part of the treatment/recovery plan • Important for clinicians to communicate to other providers about presence and potential effects of traits • Not important to have pt. arrive at acceptance of a specific diagnosis

  28. What have we learned? • Identifying trauma and characterologic issues early as possible is important • 4th step and enneagram are helpful in bringing relapse issues into the light • It is not so important to diagnose except to communicate with other treaters • People are willing to get rid of things that they deem as non-functional. • On going attention to this by “monitoring” groups might be important – group 4th step work and or enneagrams might be useful

  29. Scott Teitelbaum Depth & power of Steps 4, 5, 6 & 7

  30. Depth of the Steps • Underestimated by many professionals • More than just meetings • Ability to assess personality styling • Open the door to transformation of personality

  31. Spiritual Principles – Psychiatric Counterparts • Step 1 – honesty • Step 2 – hope • Step 3 – faith • Step 4 – courage • Step 5 – integrity • Step 6 – willingness • Step 7 – humility • Step 8 – brotherly love • Step 9 – justice • Step 10 – perseverance • Step 11 – spirituality • Step 12 – service

  32. Resentments • “For when harboring such feelings we shut ourselves off from the sunlight of the Spirit. The insanity of alcohol returns and we drink again. And with us, to drink is to die”. • Common cause of relapse • Reflects a deep spiritual problem • Fear and hurt underlie the anger

  33. 4th Step • Personal Inventory • Explores - resentments, fears, wounds, secrets • Looks for character defects to remove • Can be used as a diagnostic tool?

  34. Ken Thompson 4th Step by the columns

  35. 4th Step – 4 columns

  36. “ The Ouch” “Spiritual Wound”

  37. Self centered fear “ The Ouch” Personality Styling “Spiritual Wound” Move on to steps 5, 6, & 7

  38. Common Doctor Defects • Perfectionism • Care taking • People pleasing • Intellectualism • Arrogance-entitlement • Workaholism

  39. Ken Thompson & Scott Teitelbaum Observations

  40. The Barriers to a 4th step May not see the resentment or too ashamed to address it May negate the resentment since they realize they did something wrong as well Not emotionally connected May not feel the ouch Not able to see impact on security Not able to see the fear May continue to justify the behaviors Do not see connection to “wound” Do not see them as still active in life

  41. Case studies

  42. All of us Barriers

  43. Barriers • Religious perceptions • Morality as issue • Lack of understanding of 12 steps

  44. Greg Gable, Scott Teitelbaum, Ken Thompson what we have learned

  45. Diagnostic Issues • Danger in diagnosing personality disorder too early in treatment process • Danger in diverting patient focus from addiction to “psychological issues”

  46. What we have learnedCharacter Defects • Require energy to maintain • Driven by “wound” • Create distress • Distress may look like anxiety, depression • Attempts to medicate is common (by client but also by “psychiatrists”)

  47. What we have learned • Important to bring the traits/defects into awareness • Important to make work on the traits part of the treatment/recovery plan • Important for clinicians to communicate to other providers about presence and potential effects of traits/defects • Not important to have pt. arrive at acceptance of a specific diagnosis

  48. What have we learned? • Identifying trauma and characterologic issues early as possible is important • 4th step is helpful in bringing relapse issues into the light • People are willing to get rid of things that they deem as rotten. • On going attention to this by “monitoring” groups might be important – group 4th 5th step work

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