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

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Presentation on theme: "4 th – 5 th Step Workshop Greg Gable, PsyD Scott Teitelbaum, M.D., FASAM Ken Thompson, M.D., FASAM."— Presentation transcript:

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

2 INTRODUCTION Ken Thompson

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

4 RELEVANT RESEARCH & PSYCHOLOGICAL OBSERVATIONS Greg Gable

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% _____  <11122%  %  %  >1048%_____ Gable 2002

11 Drug of Choice RelapseNon-relapse Opioid2346%2244% Non-opioid2754%2856% Gable 2002

12 Relapse Relevance Condition relapsenon-relapse Abuse *2652%2245% Family SUD3061%37 75% Eating Disorder1020%1121% Compulsive Behaviors 1530%11 21% _________________ * Emotional/Physical/Sexual Abuse Gable 2002

13 Relapse Relevance The presence of an Axis II disorder was strongly related to relapse –(χ² = , 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 OCPD48%0 0% NPD24%00% BPD24%00% PD NOS1530%48% 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 relapsenon-relapse Bipolar612% 1 2% MDD1224% 714% Dysthymic12% 24% Bulimia36% 36% PTSD12% 12% Anxiety/Panic36% 00% OCD12% 00% Sexual 12% 00% ADHD12% 00% (43% of overall sample had a comorbid Axis I dx) Gable 2002

17 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 = , df=1, p<.05). (p actually computed to.000) Gable 2002

18 Relapse Relevance Relapse Status f % of group Relapse4182% No Relapse1734% 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 4 th 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 4 th 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 4 th step work and or enneagrams might be useful

29 DEPTH & POWER OF STEPS 4, 5, 6 & 7 Scott Teitelbaum

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

34 4 TH STEP BY THE COLUMNS Ken Thompson

35 4 th Step – 4 columns I’m resentful atThe causeAffects myCharacter defects

36 I’m resentful atThe causeAffects myCharacter defects Father Bob - peer

37 I’m resentful atThe causeAffects myCharacter defects FatherUnemotional High expectations Never attended any of my sports activities Physically abusive BobAttention to my wife Did not pay money he owed Took my job

38 “ The Ouch” “Spiritual Wound” I’m resentful atThe causeAffects myCharacter defects FatherUnemotional High expectations Never attended any of my sports activities Always at work Physically abusive Self esteem Sense of comfort Security BobAttention to my wife Did not pay money he owed Took my job Sex relations Financial security

39 “Spiritual Wound” I’m resentful atThe causeAffects myCharacter defects FatherUnemotional High expectations Never attended any of my sports activities Always at work Physically abusive Self esteem Sense of comfort Security Emotionally distant Perfectionistic Entitled BobAttention to my wife Did not pay money he owed Took my job Sex relations Financial security Wrath, vengeful Lust Personality Styling Self centered fear “ The Ouch”

40 Common Doctor Defects Perfectionism Care taking People pleasing Intellectualism Arrogance-entitlement Workaholism

41 OBSERVATIONS Ken Thompson & Scott Teitelbaum

42 I’m resentful atThe causeAffects myCharacter defects FatherUnemotional High expectations Never attended any of my sports activities Always at work Physically abusive Self esteem Sense of comfort Security Emotional distant Isolative Arrogant Entitled BobAttention to my wife Did not pay money he owed Took my job Sex relations Financial security Wrath, vengeful Lust Greed May not see the resentment or too ashamed to address it May continue to justify the behaviors Do not see connection to “wound” Do not see them as still active in life May not feel the ouch Not able to see impact on security Not able to see the fear May negate the resentment since they realize they did something wrong as well Not emotionally connected The Barriers to a 4 th step

43 CASE STUDIES

44 BARRIERS All of us

45 Barriers Religious perceptions Morality as issue Lack of understanding of 12 steps

46 WHAT WE HAVE LEARNED Greg Gable, Scott Teitelbaum, Ken Thompson

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

48 What we have learned Character 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”)

49 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

50 What have we learned? Identifying trauma and characterologic issues early as possible is important 4 th 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 4 th 5 th step work

51 THE FUTURE

52 The Future Operationalizing group – captive audience in monitored physician groups Encouragement of working steps – possible reduction in relapse Ability to see changes in recovery trajectory

53 Operationalizing Method of the group Findings by consensus Measurable components of the 4 th - 5 th step group


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