2013
Group Intervention
for Amphetaminetype Stimulant use
(GIATS)
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
© Lynne E. Magor-Blatch1.2.3. & James A. Pitts4.
1.
University of Canberra, 2. University of New South Wales, 3. Australasian Therapeutic
Communities Association
4.
Odyssey House McGrath Foundation
This work is copyright. You may download, display, print and reproduce this material in unaltered form only
(retaining this notice) for your personal, non-commercial use or use within your organisation. All other rights
are reserved. Requests and enquiries concerning reproduction and rights should be addressed to
Lynne Magor-Blatch, PO Box 464, Yass NSW 2582.
ISBN: 978-0-9875276-2-2
Page 2
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Contents
Acknowledgements
Project Background
Who the GIATS has been designed for
Required skills and knowledge
Motivational Interviewing Framework
Introduction
Clinical criteria
Clinical history
Withdrawal
Methamphetamine withdrawal
Management of comorbid psychosis
When and how to refer to mental health services
5
7
10
10
11
13
14
16
17
17
18
19
Section 1: Clinical Assessment
21
Comprehensive assessment
Assessing readiness for change
Mental health assessment
Screening for depression and anxiety
The PsyCheck Screening Tool
Section 1: General mental health screen
Section 2: Suicide/Self-harm risk assessment
Section 3: Self reporting questionnaire (SRQ)
Screening for psychosis
Section 2: Tip Sheets
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
Dose effects of amphetamines & Effects of methamphetamine use
Managing acute toxicity
Managing aggressive or agitated behaviour
Some facts about Cravings
Drug Treatment Metaphor
Pavlov’s Dog
The Bridge Concept
Managing your Feelings in Recovery
The Fight or Flight Response
Coping with Anxiety: Bodily Symptoms
(Changing) The Anxiety Cycle
Ten Most Common Relapse Dangers & High-Risk Situations
© Lynne E. Magor-Blatch & James A. Pitts
23
24
24
25
25
26
26
26
27
29
31
32
33
34
35
36
38
40
42
44
45
46
Page 3
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Section 3: Treatment Modules
47
Group Intervention for Amphetamine-type Stimulant use (GIATS)
Trial of the GIATS: First Study
Evaluation of the GIATS: Outcome study
Combining Cognitive Behavioural Therapy, Acceptance and Commitment Therapy
and Mindfulness
Importance to the AOD field
Module 1: Building motivation for change
Module 2: Understanding and coping with cravings
49
50
51
51
Acceptance and Commitment Therapy (ACT)
Module 3: Understanding how thoughts influence behaviour
Module 4: Understanding feelings and making the Mind/Body
connection
Module 5: Learning to deal with anxious thoughts and feelings
Module 6: Understanding and acknowledging core beliefs and values
Module 7: Relapse Prevention
Worksheet 1: Timeline Follow Back
Worksheet 2: Stages of Change Ladder
Worksheet 3: Psychosis screener
Worksheet 4: Lifestyle issues causing problems in my life
Worksheet 5: Decisional balance
Worksheet 6: Vitality vs. Suffering
Worksheet 7: Vitality vs. Suffering Diary
Worksheet 8: Unhelpful thinking patterns
Worksheet 9: Self monitoring record
Worksheet 10: Understanding how we experience Feelings
Worksheet 11: Feelings of Anger, Loss, Shame and Guilt
Worksheet 12: Pleasant Events Calendar
Worksheet 13: Anxiety Anxious Automatic Thoughts Questionnaire
Worksheet 14: Coping Statements for Anxiety
Personal Values Card Sort
Worksheet 15: Ranking of Personal Values Card Sort
Worksheet 16: Personal Values Exercise
Worksheet 17: Values ‘Bull’s Eye’
Worksheet 18: Cultivating Positive Affirmations and Vision
Worksheet 19: My Relapse Dangers
Worksheet 20: Problem Solving
Worksheet 21: Relapse Prevention Plan
Page 4
75
79
83
87
Section 4: Worksheets
References
53
55
61
64
67
71
89
90
91
92
93
94
95
96
98
99
100
101
102
103
104
113
114
116
117
118
119
120
121
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Acknowledgements
The GIATS has drawn on a number of sources, including:
Baker, A., Kay-Lambkin, F., Lee, N.K., Claire, M. & Jenner, L. (2003). A brief cognitive behavioural
intervention for regular methamphetamine users. Canberra: Australian Government
Department of Health and Ageing.
Lee, N., Johns, L., Jenkinson, R., Johnston, J., Connolly, K., Hall, K. & Cash, R. (2007). Clinical
Treatment Guidelines for Alcohol and Drug Clinicians. No 14: Methamphetamine dependence
and treatment. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc.
The GIATS has been enhanced through attendance by the principal author at three valuable
experiential workshops, from which information has been sourced and utilised with permission of
the authors:
· Liana Taylor, Mindfulness-Based Cognitive Therapy, experiential intensive course and
professional development, Canberra, 12 – 15 February, 2009.
· Dr Chris Wagner, Adapting Motivational Interviewing to a Group Counselling Setting, Sydney,
9-10 March, 2009.
· Dr Russ Harris, ACT MINDFULLY: Acceptance & Commitment Therapy Training, Canberra,
23-24 March, 2009.
The authors also wish to acknowledge the valuable help and support of the following people who
provided input through teaching, expert comment and critical appraisal in the development of the
GIATS:
Assoc. Professor Robert Ali
Drug and Alcohol Services, South Australia
Professor Amanda Baker
NHMRC Research Fellow Centre for Brain and Mental Health
Research, University of Newcastle
Professor Jan Copeland
Director, National Cannabis Prevention & Information Centre &
Assistant Director, National Drug and Alcohol Research Centre
Dr John Howard
Senior Lecturer, National Cannabis Prevention and Information
Centre, National Drug and Alcohol Research Centre
Dr Russ Harris
ACT MINDFULLY, Psychological Flexibility Pty Ltd
Dr Nicole Lee
Turning Point, Melbourne
Dr Rebecca McKetin
National Drug and Alcohol Research Centre, Sydney
Dr Joel Porter
Director, The Pacific Centre for Motivation & Change, New Zealand
Professor Debra Rickwood
Centre for Applied Psychology, University of Canberra
Liana Taylor
Co-Founder, Director of Training, Mindfulness Centre, Adelaide
Assoc. Professor Chris Wagner
Virginia Commonwealth University, USA
The authors would also like to thank representatives of the following Therapeutic Communities who
contributed to the development of the GIATS through consultations in Australia and New Zealand:
Queensland:
Fairhaven, Goldbridge, Logan House, Mirikai, WHOS Najara
New South Wales:
Blue Mountains Recovery Services, The Buttery, Odyssey House,
Selah Farm, The Peppers, WHOS, Wollongong Crisis Centre
Victoria:
Odyssey Vic, YSAS, YSAS Birribi, Windana
Western Australia:
Cyrenian House, Palmerston Farm, Serenity Lodge
Australian Capital Territory:
ADFACT/Karralika, Canberra Recovery Services, Ted Noffs
Foundation
Northern Territory:
Drug and Alcohol Services Association, Alice Springs
South Australia:
The Woolshed, Kuitpo Community: UnitingCare Wesley Adelaide Inc.
New Zealand:
Higher Ground Trust, Odyssey House Auckland
© Lynne E. Magor-Blatch & James A. Pitts
Page 5
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Page 6
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Project Background
The Amphetamine-type Stimulants (ATS) Grants Program was established by the Australian
Government in 2008 to enhance the capacity of non-government organisations (NGOs) to respond to
the rising demand of users of ATS.
The aim of the program was to reduce the harms caused by ATS to individuals, their families and the
Australian community. This was provided as one-off funding to allow NGOs to cater for and treat ATS
users, to attract ATS users into treatment and/or to increase referrals of ATS users into treatment
services.
It was expected that treatment interventions funded through the ATS Grants program should:
1. Reduce and treat the use of illicit drugs;
2. Be informed by evidence and use models of good practice;
3. Reduce the risk of infectious disease;
4. Improve physiological and psychological health;
5. Reduce criminal behaviour; and
6. Improve social functioning.
Odyssey House McGrath Foundation was successful in gaining funding support to develop a
treatment protocol for people who are adversely affected due to their use of ATS. While the
treatment protocol was specific for use in the Therapeutic Community (TC) environment, it was
anticipated that the protocol would also be useful in other treatment settings, including residential
treatment environments and outpatient settings. Subsequent evaluation of the treatment protocol
confirmed its effectiveness for other substance-use groups and its application in both individual and
group settings.
The initial project was conceptualised in three stages:
Stage 1: A literature review outlining background issues, problems associated with ATS use and
treatment interventions available at that time.
Stage 2: Consultation with members of the National Drug and Alcohol Research Centre and other
research institutes with expertise in research on ATS.
: Consultation with members of the Australasian Therapeutic Communities Association
(ATCA) through forums organised at jurisdictional level, including New Zealand.
Stage 3: Development of the treatment protocol for people dependent on ATS in a TC environment.
This was undertaken in two phases – the development of a draft protocol, trialled and
evaluated within selected TCs; and the development of the final protocol following
refinement through consultation and evaluation.
The original treatment package contained two documents. The Literature Review, Report of
Consultations and Trial in the Development of a Treatment Protocol for clients of Therapeutic
Communities (Magor-Blatch & Pitts, 2009), provided a review of the national and international
literature available at that time in relation to treatment for clients with ATS dependencies, an
overview of therapeutic communities and report of consultations in Australia and New Zealand with
TCs, practitioners and researchers. Included in the report was information on the development of
treatment interventions in Australia and report of Australian studies focussing on ATS users. The
final section in the report provided results from the initial trial of the Treatment Protocol with clients
of Mirikai on the Queensland Gold Coast and Cyrenian House in Perth, Western Australia.
© Lynne E. Magor-Blatch & James A. Pitts
Page 7
Group Intervention for Amphetamine-Type Stimulants (GIATS)
The Treatment Protocol for use by staff & clinicians working with ATS clients of Therapeutic
Communities was developed after extensive consultations with those working with ATS clients in
therapeutic communities in Australia and New Zealand, research institutes and others with expertise
in research, clinical practice and the development of clinical interventions.
In 2013, following the evaluation of the effectiveness of the treatment protocol, some changes were
made to the materials. The treatment protocol was also renamed as the Group Intervention for
Amphetamine-type Stimulant use (GIATS). The GIATS draws heavily on both the collected
information from consultations and on other treatment manuals, interventions and guidelines which
have been developed within Australia and overseas in working with this client group. The authors
are grateful to others, including researchers and authors, who provided permission for the use of
material for inclusion in this treatment manual.
When the project first commenced, we believed we would be developing a ‘protocol’ which outlined
a procedure for use by staff – a treatment manual rather than treatment guidelines. During the
consultation process, it became clearer that while a manualised approach, or ‘protocol’ remained an
important resource, a series of ‘tip sheets’ and materials that could be added to the package and
used flexibly would be of great overall value. Therefore the GIATS includes tip sheets, worksheets
and activities that may be used flexibly. At the same time, each module flows on from the one
before – although there remains the option to use some as stand-alone interventions in either a
group or individual setting.
The evaluation of the GIATS was undertaken between 2009–2013 through a quasi-experimental
study that assessed outcomes for ATS users accessing treatment in 11 Australian TCs, and included
participants who received the intervention (n=125; 83 males and 42 females) compared with
Treatment as Usual (TAU) (n=122; 75 males and 47 females). Participants were interviewed and
completed self-report questionnaires of psychosocial measures at T1 (baseline: Time 1) entry to the
study and at two follow-up points over 18 months. Results provided an important profile of ATS
users, describing their severity of dependence, history of lifetime and current substance use, and
severe symptomatology on mental health and psychosocial measures.
Participants completed two self-report questionnaires, which included a number of validated
measures, on recruitment to the study. Questionnaire A included:
· Questions selected from the Brief Treatment Outcome Measure (BTOM; Lawrinson,
Copeland, & Indig, 2003)
· Severity of Dependence Scale (Amphetamines and other ATS use) (SDS; Gossop, Best,
Marsden, & Strang, 1995)
· Lifestyle issues for seeking treatment (adapted from the 2007 New Zealand Illicit Drug
Monitoring System (IDMS) survey
· The Depression Anxiety Stress Scale (DASS-42; Lovibond & Lovibond, 1995a)
· Novaco’s Dimensions of Anger Reactions Scale 5 (DAR5; Novaco, 1975)
· Behavioural Rating Inventory of Executive Function - Adult Version Self Report Form
(BRIEF-A; Roth, Isquith, & Gioia, 2005)
· The Short Form-36 Version 2 (SF-36v2; Ware, Gaudek, & IQOLA Project Group, 1994)
Questionnaire B comprised:
· Millon Clinical Multiaxial Inventory – III (MCMI-III; Millon, Millon, Davis, & Grossman,
2009)
Page 8
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Questionnaire A was administered at baseline, six months post baseline and again at 12–18 months
after discharge from treatment. Questionnaire B was administered only once, at baseline. A third
measure, the Timeline Follow Back, was also administered to participants at entry.
Results at T2 (six-eight months post-baseline) on measures of metal health and wellbeing showed
both groups significantly improved over baseline, with the Intervention group showing greater
statistical and clinical improvement from baseline when compared with TAU participants. Results
for both groups at T3 (second follow-up: 12-18 months post-baseline) showed statistically significant
and clinical improvement over baseline on a number of measures.
While statistically significant differences were found between groups at T3 in only one area - an
improvement on one of the measures of executive functioning (Self-Monitor), participants
significantly improved from baseline on measures of mental and physical health, psychopathology,
executive function and aggression. Additionally, participants receiving the GIATS recorded less
substance use and criminal offending at T3 follow-up, providing evidence to support the
effectiveness of the intervention. These results are particularly encouraging, given the severe
deficits in cognitive functioning and level of comorbid presentations that were evident within this
both Intervention and TAU groups at baseline, and continuing on some measures into follow-up.
The GIATS contains information which can be used flexibly in working with clients within the TC and
other treatment settings. Tip Sheets and activities for staff and clients are provided to assist in
understanding and working with the sometimes complex behaviours and issues relating to mental
health problems that can be experienced by clients who have been using ATS and other substances.
These also form a resource for families and professionals both within and outside the TC to assist in
better understanding some of the issues and to develop strategies which may help in working with
complex clients, both on a personal and professional level.
Lynne E. Magor-Blatch PhD, MAPS, MCFP
M.Psych (Forensic); B.A. (Hum. & Soc.Sci.); Grad.Dip.App.Psych.
Dip.Teach. (Sec); Cert IV TAA
James A. Pitts MA
© Lynne E. Magor-Blatch & James A. Pitts
Page 9
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Who the GIATS has been designed for
The GIATS was developed after consultation for staff and clinicians working within Therapeutic
Communities (TCs) and associated programs and refined through pilot study and evaluation. While
the prime focus of the material contained within this treatment package is clients with problems
associated with the use of Amphetamine-Type Stimulants (ATS), it is recognised that many clients
experience an array of problems, and particularly mental health problems, resulting from the use of
a range of substances. Therefore, it is anticipated that the material contained in this treatment
package will also be of use to staff who are working with clients with complex behaviours resulting
not only from ATS use, but also from other substance use, either in combination or in isolation.
Staff and clinicians utilising this material are also encouraged to access and consider other materials
which have been developed both in Australia and overseas. Research into ATS use is continuing and
information about treatment interventions will continue to be developed as the results of further
studies become available.
Required skills and knowledge
It is expected that all staff and clinicians will have experience in working with clients with complex
behaviours utilising the tools and interventions specific to their treatment modality. For staff within
the therapeutic community environment, it is recognised that TCs differ from other treatment
approaches principally in their use of the community, comprising treatment staff and those in
recovery, as key agents of change. This approach is referred to as ‘community-as-method’.
TC members interact in structured and unstructured ways to influence attitudes, perceptions, and
behaviours which are considered to be associated with substance use. In addition to the importance
of the community as a primary agent of change, other fundamental TC principles are ‘self-help’ and
‘mutual help’. Self-help infers that clients are responsible for participating and contributing to the
TC process to change their behaviours. By mutual help, we mean that clients assume responsibility
for helping their peers. Both concepts of mutual and self-help reinforce the recovery process.
The unique aspects of the TC as a modality were an important consideration in the development of
the treatment package. While we have certainly utilised and ‘borrowed’ from the many excellent
interventions which have already been developed, the focus has been very much on working with
clients within a group setting, which is the hallmark of TC treatment. However, as all TCs provide the
opportunity for both individual and group counselling, depending on the need of the individual and
of the community, the GIATS has been designed for both applications.
In the consultation process, a number of different treatment interventions were reviewed and
suggested. These included interventions based on the use of Cognitive Behavioural Therapy (CBT),
Motivational Interviewing (MI), Mindfulness-based interventions (Mindfulness-based Stress
Reduction (MBSR) and Mindfulness-based Cognitive Therapy (MBCT), Acceptance Commitment
Therapy (ACT) and other therapeutic interventions. The GIATS and associated materials within the
treatment package have utilised strategies from all of these interventions. Some will already be
known to staff and clinicians, others will be new.
Included in the GIATS are a number of suggested activities and exercises, together with Tip Sheets
and ideas for additional therapeutic interventions. Staff who are not trained in their use should
undertake training before practising the suggested activities or treatment interventions.
Page 10
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
It needs to be acknowledged that some clients with mental health problems, including comorbidity
associated with their ATS use, may be vulnerable and at risk. Therefore it is important that staff only
utilise those interventions with which they feel confident, and in which they have been trained.
Motivational Interviewing Framework
Motivational Interviewing is a client-centred, directive method for enhancing intrinsic motivation to
change by exploring and resolving ambivalence. While the first module of the GIATS specifically
focuses on building motivation for change, the GIATS is embedded in the use of motivational
interactions and techniques. Information and literature on the use of motivational interviewing with
groups is in the evolving stages. Dr Chris Wagner and his colleagues, Karen Ingersoll and Sandra
Gharib have co-authored Motivational Groups for Community Substance Abuse Programs, and
Motivational Interviewing in Groups (Applications of Motivational Interviewing) (Wagner & Ingersoll,
2013). In the development of the GIATS, the principal author attended a workshop facilitated by Dr
Chris Wagner and supported by Dr Joel Porter, Director of the Pacific Centre for Motivation and
Change. This was invaluable in helping to synthesise the ideas around the way in which the GIATS
should be delivered.
Motivation for change occurs when people perceive a discrepancy between where they are and
where they want to be. The use of motivational interviewing techniques within the group setting
should therefore seek to enhance and focus the client's attention on such discrepancies with regard
to their drug use. The first module of the protocol develops this discrepancy by raising the client's
awareness of the adverse personal consequences of his or her drug use. This information, properly
presented, can precipitate a crisis of motivation for change. As a result, the person may be more
willing to enter into a discussion of change options, in order to reduce the perceived discrepancy and
regain emotional balance (Miller, 1995).
Motivational Interviewing (MI) is not a ‘treatment’ but a way of ‘being with’ (Dr Chris Wagner, the
use of MI with Groups Training Workshop, Sydney 9-10 March, 2009). The group core concepts
(presented by Dr Wagner) are:
1. Therapeutic Factors – Hope, Universality, Altruism, Information, Socialising (Inspiration,
Support);
2. Interpersonal Learning – Relationships, Corrective emotional experience, Group as a social
microcosm;
3. Therapist tasks - Shaping norms, Working in the here-and-now, Utilising process orientation;
and
4. Person-centred groups:
a. Growth conditions: Genuineness, Acceptance, Empathy
b. Person-centred vs. Expert leader groups
c. Rogers’ group stages/process patterns – Unfocused; Past feelings; Present individual
feelings and concerns; Interpersonal engagement between group members;
Reduction in defences; Opening to new experiences; Deepening; New ways of being
The use of MI with groups draws on techniques used in individual therapy. Both build motivation to
change by helping people to become ‘unstuck’; both balance client-centred and directive elements;
both use the same communication style and strategies; and both avoid non-adherent clinical
behaviours (Dr Chris Wagner, MI with Groups Workshop, 9-10 March, 2009).
The differences essentially lay in the dynamics of the group – managing ‘floor time’, different styles
and beliefs across members, eliciting group energy for change, working with group members to
facilitate communication and balancing the facilitation vs. interviewing processes. The group setting
© Lynne E. Magor-Blatch & James A. Pitts
Page 11
Group Intervention for Amphetamine-Type Stimulants (GIATS)
is not meant to be a series of individual conversations or therapy sessions, but a process whereby all
members are included to support and challenge ideas.
Dr Wagner, in presenting the MI with Groups workshop, drew out the following in the facilitation of
MI groups:
a. Focus on positives
b. Bring the group into the moment
c. Explore perspectives and focus on the present
d. Hear complaints, but do not elicit grievances
e. Broaden perspectives and focus on the future
f. Reflect and explore positive focus on desires, needs, plans and self
g. Counteract any negative reactions before the session ends
The group tasks therefore will include engaging and exploring issues, including values and
ambivalence; broadening and building interest and confidence in changing; and helping members
plan steps towards a commitment for change.
These are the important processes to maintain in the presentation of the following treatment
intervention.
Page 12
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Introduction
Amphetamine-Type Stimulants (ATS) are part of the psychostimulant group of drugs and include
meth/amphetamine, ecstasy, cocaine and some pharmaceuticals (such as dexamphetamine and
Ritalin). Methamphetamine comes in three common forms: powder (or ‘speed’), methamphetamine
base (or ‘base’) and crystal methamphetamine (or ‘Ice’). Ecstasy is usually in tablet form and
contains 3,4-methylenedioxymethylamphetamine (MDMA) in varying amounts combined with other
drugs such as meth/amphetamine1 and ketamine (a general dissociative anaesthetic). In Australia,
the main ATS used are methamphetamine and ecstasy (National Amphetamine-Type Stimulant
Strategy, 2008-2011).
ATS stimulate central nervous system activity by increasing synaptic concentrations of three major
neurotransmitters in the brain: dopamine, serotonin (5-HT) and noradrenaline (Rothman &
Baumann, 2003). This has the effect of producing a euphoric sense of wellbeing, wakefulness and
alertness. Use of ATS is also associated with a range of potentially negative health consequences,
including increased heart rate, blood pressure, sleeplessness and reduced appetite. There is also
greater risk of mental health issues, aggression, violence and accident resulting from unsafe
behaviours, such as unsafe driving.
Therefore methamphetamine use can be associated with a range of both positive and negative
effects. Positive effects include:
· euphoria;
· increased libido;
· alertness;
· diminished appetite;
· enhanced reflexes; and
· feelings of confidence and physical strength (ACON, 2006).
Negative effects include:
· increased heart rate and irregular heart beat;
· abdominal pain;
· sweating;
· dilated pupils;
· fatigue;
· parasitosis (picking and scratching skin);
· agitation, anxiety and paranoia;
· confusion, disorientation and hallucinations;
· psychosis; and
· violent and aggressive behaviour (ACON, 2006).
A large proportion of ATS dependent users will experience psychological problems. These will
include depression, anxiety and psychosis. Meth/amphetamine intoxication, particularly where
there is simultaneous use with alcohol and other drugs, often results in agitation and aggression and
will impact on frontline workers and families. This leads to significant resource implications for
workers and organisations, including law enforcement, mental health and alcohol and other drug
(AOD) services. The impact on families may also be dramatic, raising the need to support all family
members as well as the person using ATS.
1
Meth/amphetamine is used to refer to amphetamine and methamphetamine in instances where both forms
are relevant.
© Lynne E. Magor-Blatch & James A. Pitts
Page 13
Group Intervention for Amphetamine-Type Stimulants (GIATS)
The following Tip Sheets are included with this treatment package, and may be provided to clients,
family members and others who are supporting the person. These will provide some information to
help each person understand the possible symptoms resulting from ATS use and withdrawal:
·
·
·
Tip Sheet 1: Dose effects of amphetamines & Effects of methamphetamine use
Tip Sheet 2: Managing acute toxicity
Tip Sheet 3: Managing aggressive or agitated behaviour
Clinical criteria
According to the Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM-IV-TR)
dependence is characterised by a person experiencing at least three of the following symptoms:
· tolerance, defined as either a need to use larger amounts to achieve desired effect, or
decreased effect with continued use of the same amount of substance;
· withdrawal;
· increased dosage and duration of the substance use;
· unsuccessful attempts to cut down or control substance use;
· increased time spent to obtain the substance, use the drug or come down from the drug;
· giving up social, occupational and recreational activities because of substance use; and
· continued substance use despite knowledge of having an awareness of negative
consequences (e.g., physical or psychological problems) (American Psychiatric Association
(APA), 2000)
Additionally, the DSM-IV-TR (APA, 2000) provides a diagnostic criteria for amphetamine intoxication:
A. The patient has recently used an amphetamine or related substance, such as
methylphenidate.
B. Clinically significant maladaptive behavioural or psychological changes developed during or
shortly after the patient used amphetamines or a related substance. Such changes include
the following:
§
Euphoria or affective blunting
§
Changes in sociability
§
Hypervigilance
§
Interpersonal sensitivity
§
Anxiety, tension, or anger
§
Stereotyped behaviours
§
Impaired judgment
§
Impaired social or occupational functioning
C. Two or more of the following conditions develop during or shortly after the patient used
amphetamines or a related substance:
§
Tachycardia or bradycardia
§
Pupillary dilatation
§
Elevated or lowered blood pressure
§
Perspiration or chills
§
Nausea or vomiting
§
Evidence of weight loss
§
Psychomotor agitation or retardation
§
Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
§
Disorientation and memory loss, seizures, dyskinesias, dystonias, or coma
D. The symptoms are not due to a general medical condition, and another mental disorder does
not account for them better than amphetamine intoxication does.
Page 14
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
The DSM-IV-TR (APA, 2000) also describes the following 10 amphetamine-related psychiatric
disorders:
1. Amphetamine-induced anxiety disorder
2. Amphetamine-induced mood disorder
3. Amphetamine-induced psychotic disorder with delusions
4. Amphetamine-induced psychotic disorder with hallucinations
5. Amphetamine-induced sexual dysfunction
6. Amphetamine-induced sleep disorder
7. Amphetamine intoxication
8. Amphetamine intoxication delirium
9. Amphetamine withdrawal
10. Amphetamine-related disorder not otherwise specified
Either prescription or illegally manufactured amphetamines can induce these disorders. Prescription
amphetamines are used frequently with children and adolescents to treat attention deficit
hyperactivity disorder (ADHD), and they are the most commonly prescribed medications for
children.
Amphetamine-related psychiatric disorders are conditions resulting from intoxication or long-term
use of amphetamines or Amphetamine-type Stimulants (ATS). These disorders can also be
experienced during the withdrawal period and are often self-limiting after cessation, though, in
some cases, psychiatric symptoms may last several weeks after discontinuation. This is particularly
important for treatment agencies to understand, since it is often after the person has been accepted
into treatment in, for example, a therapeutic community, that symptoms present.
For some people, this will include paranoia during withdrawal as well as during sustained use.
Amphetamine use may also elicit or be associated with the recurrence of other psychiatric disorders.
People addicted to amphetamines sometimes decrease their use after experiencing paranoia and
auditory and visual hallucinations (Larson, 2008).
The symptoms of amphetamine-induced psychiatric disorders can be differentiated from those of
related primary psychiatric disorders by time. If symptoms have not resolved within two weeks after
discontinuation of ATS, it is advised that a primary psychiatric disorder should be suspected (Larson,
2008). Depending on the severity of symptoms, symptomatic treatment can be delayed to clarify
the etiology. However, it is important that TCs gain the support of mental health services and
consult with a psychiatrist to better assess problems related to ATS use and withdrawal.
Amphetamine-induced psychosis (delusions and hallucinations) can be differentiated from psychotic
disorders when symptoms resolve after ATS withdrawal. Absence of symptoms, including anhedonia
(the inability to gain pleasure from enjoyable experiences), avolition (a psychological state
characterised by general lack of desire, drive, or motivation to pursue meaningful goals),
amotivation (the inability or unwillingness to participate in normal social situation), and flat affect,
are further indicators of amphetamine-induced psychosis (Larson, 2008).
Amphetamine-induced delirium follows a reversible course similar to other causes of delirium, and it
is identified by its relationship to amphetamine intoxication. After the delirium subsides, little to no
impairment is observed. Delirium is not a condition which has been observed during amphetamine
withdrawal (Larson, 2008).
Mood disorders similar to hypomania and mania may be observed during ATS intoxication.
Depression may also result during withdrawal, and repeated use of ATS can produce antidepressant© Lynne E. Magor-Blatch & James A. Pitts
Page 15
Group Intervention for Amphetamine-Type Stimulants (GIATS)
resistant amphetamine-induced depression. Sleep disturbances may be evident, and these will
appear in a fashion similar to mood disorders (Larson, 2008). During intoxication, sleep can be
decreased markedly. This was observed by many of the TCs during the consultation process as being
one of the concerns in the early stages of treatment, with the after-effect, being the need for more
sleep. This is part of the withdrawal process. A disrupted circadian rhythm can result from late or
high doses of ATS.
Amphetamine-related disorder not otherwise specified is a diagnosis assigned to those who have
several psychiatric symptoms associated with amphetamine use but do not meet the criteria for a
specific amphetamine-related psychiatric disorder (APA, 2000).
Clinical history
Amphetamine-related psychiatric disorders can be confused with psychiatric disorders caused by
organic, medical, neurologic, and/or psychological etiologies. The causes of amphetamine-related
psychiatric disorders may be determined by assessing the client's history and developing a
genogram.
The DSM-IV-TR (APA, 2000) provides criteria helpful for determining if the person is in a state of
intoxication or withdrawal. The criteria helps clinicians distinguish disorders occurring during
intoxication (e.g., psychosis, delirium, mania, anxiety, insomnia) from those occurring during
withdrawal (e.g., depression, hypersomnia).
1.
Developmental history: The developmental history provides information about the client's
in utero exposure to medications, illicit drugs, alcohol, pathogens, and trauma.
o
o
As children, clients may have had prodromal symptoms of psychiatric disorders, such
as social isolation, deteriorating school performance, amotivation, avolition,
anhedonia, sleep disturbances, sexual paraphilias, poor interest, psychomotor
retardation, demoralisation, social isolation, and suicidal thoughts and behaviours.
Delinquency, truancy, educational failure, early use of drugs and alcohol,
oppositional behaviour associated with conduct disorder, and use of ATS are
developmental behaviours that suggest an amphetamine-related psychiatric
disorder.
2.
Psychiatric history: Two issues are emphasised:
o Determine whether a psychiatric disorder or symptoms ever occurred when the
client was not exposed to amphetamines.
o Determine whether the client ever had a psychiatric disorder or symptoms similar to
the present symptoms in relation to any other drug or medication.
3.
Recent history: The client's history of ATS use is the most important factor and is
determined by asking the following questions:
o When did ATS use start?
o What is the nature of ATS use (e.g., speed, methamphetamine, and if so, what
type?)
o How often does the person use ATS?
o How much is being used?
o Is the person currently intoxicated or in withdrawal?
o Has the client recently increased his or her ATS use or started to binge?
Page 16
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
4.
Substance abuse history: Take a full substance use history.
5.
Family history: A family history of a psychiatric disorder may suggest a primary psychiatric
disorder. A diagnosis of amphetamine-related psychiatric disorder might still be possible if
the client has no family history of psychiatric disorder.
Withdrawal
The DSM-IV-TR (APA, 2000) criteria for amphetamine withdrawal are as follows:
A. Cessation of (or reduction in) use that has been heavy or prolonged.
B. Dysphoric mood and two (or more) of the following physiological changes developing
within a few hours to several days after Criterion A:
1. Fatigue
2. Vivid, unpleasant dreams
3. Insomnia or hypersomnia
4. Increased appetite
5. Psychomotor retardation or agitation
C.
D.
The symptoms in Criterion B cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
The symptoms are not due to a general medical condition, and are not better accounted
for by another mental disorder.
Methamphetamine withdrawal
Lee and associates (2007) in Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No 14:
Methamphetamine dependence and treatment, detail methamphetamine withdrawal syndrome as
predominantly characterised by adverse psychological symptoms, such as extreme fatigue and
irritability. The DSM-IV-TR characterises methamphetamine withdrawal as including dysphoric
mood (sadness) plus two of the following:
• fatigue
• insomnia
• hypersomnia (over-sleeping)
• psychomotor agitation
• increased appetite
• vivid, unpleasant dreams (APA, 2000).
Drug cravings, paranoid or suspicious thoughts, and feeling angry, aggressive or emotional are other
symptoms commonly associated with methamphetamine withdrawal. Withdrawal symptoms from
methamphetamine may mimic the symptoms of acute intoxication, particularly agitation and hyperarousal (Jenner & Saunders, 2004). While there is some evidence to suggest that the majority of
symptoms of withdrawal will resolve within a week of ceasing methamphetamine use, with sleep
and appetite related symptoms persisting for a further one to two weeks (McGregor, Srisurapanont,
Jittiwutikarn, Laobhripatr et al., 2005) this may be influenced by a number of factors:
• age (older and more dependent users may experience a more severe withdrawal)
• general health
• mode of administration
• quantity and purity of methamphetamine being used prior to cessation
• polydrug use
© Lynne E. Magor-Blatch & James A. Pitts
Page 17
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Anecdotal evidence from the consultation process with TCs suggests symptoms of withdrawal may
persist for longer periods, with the consensus being that clients may experience symptoms for up to
four to six weeks, and that up to the first 12 weeks of treatment may be adversely affected.
Dependent users are also likely to undergo withdrawal many times as use fluctuates between heavy
use, regular use and periods of intermittent or binge use. Self-detoxification is common and
polydrug use by ATS users may serve the purpose of managing some of this process.
TCs are amongst the specialist services that are most likely to see methamphetamine users who
have suffered from depression, experienced psychotic symptoms such as hallucinations and
paranoia, or have experienced behavioural problems, such as aggressive outbursts. All of these
behaviours were reported as part of the consultation process. These clients require skilled clinicians
and a range of resources in order to manage these complexities.
Management of comorbid psychosis
A small, but significant percentage of users will experience methamphetamine-induced psychosis.
Typically, this will occur following heavy binge or prolonged use, however, little is known about
Australian prevalence rates (Dawe & McKetin, 2004).
Lee and associates (2007) report that symptoms of a methamphetamine-induced psychosis usually
resolve within a few days after ceasing use. Nevertheless, this can be an extremely stressful event,
with clients worrying that their use of methamphetamine may lead to a permanent psychotic
disorder. During the consultations some TCs reported this occurrence, sometimes leading to clients
being treated by mental health teams and in some cases, being admitted to psychiatric care for a
period of time before returning to the TC.
Clinicians should be aware that a period of abstinence (from methamphetamine) and improved selfcare is likely to alleviate many symptoms without psychiatric intervention. However, in a small
group of users, symptoms may worsen immediately after cessation of methamphetamine use
(during withdrawal) but usually settle over a relatively short period of time – a matter of days or
weeks (Lee, et.al., 2007). If symptoms resolve within a month of ceasing methamphetamine use, it
is likely to have been a drug-induced psychosis. For others, psychotic symptoms may persist for a
longer period of a month or more (Dawe & McKetin, 2004). This may suggest a more enduring
psychiatric condition.
The issue of whether or not the symptoms of psychosis have been triggered by methamphetamine
or other drug use, or whether there was a pre-existing vulnerability to schizophrenia has often
concerned those working in both the AOD and mental health fields (Dawe & McKetin, 2004). In the
acute phase, this issue is not of immediate concern. At this point, the presenting symptoms rather
than the underlying cause are the treatment focus. If psychotic symptoms worsen during treatment,
then it is likely that there is an underlying mental health issue and psychiatric assessment and
intervention may be required. Acute symptoms should be managed as a priority (Lee, et.al., 2007).
A number of TCs reported having clients on ongoing anti-psychotic medications where symptoms
had not abated, and in some cases had increased. Once medication is stabilised, the person is
generally able to continue within the TC and to take part in all program interventions. The
treatment protocol should be offered once the symptoms of psychosis have resolved.
Page 18
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
When and how to refer to mental health services
All TCs in the consultation reported having professional relationships, including Memoranda of
Understanding, with mental health services. Many had a consultant psychiatrist as part of the
program clinical team. Lee and colleagues (2007) note there are four main reasons for making
contact with a mental health service on behalf of a client. These are:
1. If it is suspected that the client has an undiagnosed or untreated psychotic disorder.
For example, if the client appears to hear or see things that others don’t
(hallucinations) or to hold delusional beliefs or to demonstrate bizarre behaviour –
especially if these symptoms persist after a period of detoxification and stabilisation.
2.
If there is a concern that the client has an undiagnosed or untreated bipolar disorder,
as indicated by the presence of manic symptoms such as a decreased need for sleep or
food, a marked period of productivity, a rapid flow of thoughts or speech and an
exaggerated sense of self-esteem or invincibility.
3.
If there is a concern or a high risk of suicide or self-harm.
4.
If there is a concern about the person’s ability to respond to treatment.
All TCs reported staff had an improved ability to respond to comorbid presentations, and all reported
a level of mental health training. Nevertheless, the need to maintain specialist service relationships
was seen as both a concern and a priority by all during the consultation phase.
Of particular concern for TCs was a belief that in some cases mental health services had possibly
viewed the TC as a ‘safe place’ for the client and therefore, after assessment, the intervention which
the TC had expected, had not been delivered. This did not necessarily mean removal of the person
from the TC into mental health care, but a better process of joint case management between the TC
and mental health services. Balancing the needs of the individual against those of the community
when a crisis occurs was reported as a concern for many TCs.
The need for better communication between mental health and TCs was therefore cited as a priority.
Included in this is the need to educate mental health and other medical services about the capacity
of TCs to respond to crisis situations and to work with people with comorbid presentations. It is clear
that TCs do work with very chaotic and complex clients. However, all noted that the balance within
the community, including the numbers of clients within the program with complex behaviours, is
something which needs to be continually monitored. This is especially important in the early stages
of treatment, since it is likely that TCs will primarily deal with these issues during this phase. Hence
there is a concern expressed by TCs regarding the number of clients and their degree of complexity in
relation to comorbidity concerns, which the TC can admit and adequately treat, at any one time.
The point at which clients often stabilise is also the point at which they may move to the second
stage of the program. Therefore it is during the early treatment phase that TCs require increased
support.
© Lynne E. Magor-Blatch & James A. Pitts
Page 19
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Page 20
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Section 1:
Clinical Assessment
© Lynne E. Magor-Blatch & James A. Pitts
Page 21
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Page 22
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Comprehensive assessment
Conducting a comprehensive assessment is the first important step in developing a treatment plan
for the client. It provides a baseline of information from which treatment can be designed and
implemented. All TCs currently have in place an assessment process and protocol which have been
designed to meet their needs. This treatment package will not therefore duplicate any of this
general material, but will provide some additional materials which may be used to assist assessment.
Also provided is a mental health assessment format for consideration. However, TCs that have
already adopted the PsyCheck materials will be familiar with this material and others may already
have in place assessment formats to collect the information. Where these are not already in place, it
would be useful to review current materials in relation to those provided within this treatment
package.
The majority of people who use methamphetamines are polydrug users, and therefore ATS use is
seen in conjunction with other drug use. As reported as part of the consultation process, mental
health symptoms are common and at least require screening for all methamphetamine users.
Engagement is often cited as a barrier to treatment for methamphetamine users, therefore it is
important to assess readiness for treatment as part of this process (Lee, et.al., 2007).
Lee and colleagues (2007) outline the necessary core elements of the drug use component of
assessment for methamphetamine users as including:
• accurate information about all aspects of methamphetamine use
• indicators of severity of dependence, withdrawal symptoms and significant periods
of abstinence
• evidence of dependence on, or withdrawal from other drugs
• risk behaviour associated with mixing drugs, including overdose or toxicity
• psychosocial factors
• treatment goals
The assessment or clinical interview is also important in order to gather accurate information about:
• type/s of methamphetamine being used
• the quantity and frequency of use
• the route of administration
• duration of use
The differences in drug use patterns between Australian and New Zealand ATS users, and
particularly methamphetamine users, were evident during the consultation process. It is important
to gather information about polydrug use, with a particular emphasis on the pattern of drug use in
relation to methamphetamine use, such as mixing other drugs with methamphetamines and using
other drugs (particularly depressants) to alleviate the ‘come down’ effects of methamphetamine.
Lee and colleagues (2007) provide a timeline follow back (TLFB) worksheet as a validated method of
understanding the recent pattern of drug use in relation to methamphetamine use, which may be
used in conjunction with the clinical interview (see Worksheet 1: Timeline follow back). This is a
calendar that records the last 30 days of use and may be of particular benefit with clients during the
assessment and pre-admission stage of treatment. It is suggested that anchors for the client should
be provided by indicating public holidays, significant personal events and other dates on the
calendar. The client should then be assisted to work back from the last day of use and complete
information about all drug use for each day.
© Lynne E. Magor-Blatch & James A. Pitts
Page 23
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Assessing readiness for change
All TCs will be familiar with the Stages of Change Model and the use of Motivational Interviewing in
assessing the client’s readiness for change. While the client may already have completed
detoxification prior to engagement with the TC, it is particularly important to explore readiness for
change and other factors that may impact on the person’s engagement in the treatment process
within the TC.
Explore the client’s concerns or reservations they have about ongoing treatment and the treatment
setting. Worksheet 2: Stages of change ladder can be used to discuss readiness to change with the
client (adapted from Biener & Abrams, 1991 cited in Lee, et.al., 2007). The worksheet is specifically
aimed at the person’s use of ATS and therefore assesses readiness to enter the TC, rather than as an
indication of readiness to address general concerns about all substance use or to complete the TC or
other AOD program. The ladder may be adapted to reflect the person’s movement through the TC
program as part of a stepped-care process. Monitor engagement closely throughout treatment and
adapt interventions accordingly. Motivational enhancement and assessment techniques may be
useful and are provided as part of the Treatment Protocol.
Mental health assessment
The high incidence of mental health problems amongst methamphetamine users has been well
documented in the literature and further developed in the Literature Review and Report of
Consultations (Stages 1 & 2) in the Development of a Treatment Protocol for clients of Therapeutic
Communities (Magor-Blatch, 2009) contained within this treatment package. All consultations
highlighted the need for a comprehensive assessment process, including the recommendation that
assessment staff and clinicians develop the skills to effectively assess and manage comorbidity
within the TC client population. As part of this, there was an agreement and recognition that
addressing both conditions as part of a coordinated approach was far more efficacious than treating
each separately or in parallel.
Baker, Kay-Lambkin, Lee, Claire and Jenner (2003) recommend a comprehensive mental health
assessment that focuses on:
• identifying symptoms of depression, anxiety and psychosis (the most common psychiatric
symptoms associated with methamphetamine use)
• the duration of symptoms
• whether symptoms are present during use or persist after methamphetamine use has
ceased
• previous treatment for mental health problems
An assessment of the comorbidity of substance use disorder and psychiatric illness should therefore
be conducted using the following prompts:
• Consider the range of symptoms caused by each identified substance.
• Determine whether substance use predated the psychiatric symptoms, using questions
such as:
o How old were you when you first experienced (symptoms)?
o How old were you when you started using (substance) regularly (at least weekly)?
• Determine duration and patterns of use and affect on psychiatric symptoms, using
questions such as:
o Has there been a time when you have not used (substance)?
o If yes, how long was this for and how did this affect your symptoms?
Page 24
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
•
Determine duration and patterns of psychiatric symptoms and affect on substance use,
using questions such as:
o Has there been a time when you have not experienced (symptoms)?
o If yes, how did this affect your use of (substance)?
Adapted from Dawe & McKetin (2004) in Lee et al., 2007.
Screening for depression and anxiety
The PsyCheck Screening Tool is an instrument that can be used to screen for high prevalence mental
health problems among alcohol and other drug populations, as well as address the most prevalent
disorders among amphetamine users. It is already being used by a number of TCs and has the
benefit of an accompanying four-session intervention to assist clinicians to manage depression and
anxiety symptoms among AOD clients. Some of the TCs in the consultation, e.g., WHOs and
Cyrenian House, have already adapted the four session intervention into a group format, for use
with TC populations.
The PsyCheck intervention is not reproduced here, and enquiries regarding its use should be directed
to the Australian Government, Department of Health and Ageing. The Screening Tool is outlined
below. All TCs report already having a mental health assessment tool in place, either as a standalone instrument or embedded within the main assessment protocol. It is important that
information gathered as part of this process is able to be translated into an intervention, should
information from the assessment indicate this need. The PsyCheck Screening Tool is particularly
useful in this regard, since it very clearly articulates into an intervention according to scores achieved
through the screening process.
The PsyCheck Screening Tool
The PsyCheck Screening Tool is a mental health screening instrument designed for use by clinicians
who are not mental health specialists. It detects the likely presence of mental health symptoms that
are often seen within AOD treatment services, and may be addressed without the specialist
interventions of mental health professionals. As PsyCheck is not designed as a diagnostic assessment
it will not yield information about specific disorders. It is designed to detect potential mental health
problems that may be missed if they are not specifically investigated by the assessment or clinical
staff or raised by the client. For this reason, it is considered important that all clients are given the
screening instrument, even if they do not appear to have a mental health problem. Some TCs in the
consultation have embedded Sections 1 and 2 within their assessment protocols and administer
Section 3 soon after the person is admitted into the TC.
The PsyCheck Screening Tool has three sections and can be used at any point in the assessment and
treatment of a client once they are stabilised (i.e., no withdrawal symptoms and/or stabilised on
pharmacotherapy). As noted, it can be readily incorporated into the regular assessments conducted
at entry to services and should also be re-administered throughout treatment, whenever other
reviews of progress are conducted (Lee, et.al., 2007).
The Self Reporting Questionnaire (SRQ) can be self or clinician administered, while the other sections
are administered by the clinician. If used as a stand-alone screening tool, it may not be necessary to
go through all the questions if some of the information (for example, hospitalisation, past history)
has already been collected.
© Lynne E. Magor-Blatch & James A. Pitts
Page 25
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Section 1: General mental health screen
Section 1 of the PsyCheck has five questions designed to identify clients who have been previously
diagnosed or treated for mental health problems. Question 5 in Section 1 of the PsyCheck is a
prompt for the presence of suicidal ideation: ‘Has the thought of ending your life ever been on your
mind?’ If the client answers ‘Yes’, a full suicide/self-harm risk assessment is conducted as indicated
in Section 2 of the PsyCheck.
Section 2: Suicide/Self-harm risk assessment
If the client answered ‘Yes’ to suicide ideation in Section 1, a full suicide/self-harm risk assessment is
required. Assessment staff and clinicians should follow organisational protocols if high risk of suicide
is identified; however Table 1 outlines potential responses to levels of risk.
Table 1. Risk levels and response to suicidality.
Level of risk
Action
No or minimal risk
•
Monitor as required.
Low risk: some thoughts but minimal risk
factors, no previous attempts, no specific plan,
intention or means, evidence of minor self harm,
protective factors (e.g., available supports).
•
Moderate risk: thoughts, some risk factors, plan
has some specific detail, means are available,
intention to act in near future but not
immediately, some protective factors (e.g.,
inconsistent supports)
•
Monitor closely and agree on a verbal or
written contingency plan with client.
Provide support numbers.
Obtain commitment to follow the
contingency plan should feelings escalate.
Offer or refer for further
assessment/contact with mental health or
other appropriate service.
Agree on a written contingency plan with
client, clearly outlining relevant supports
to be contacted if feelings escalate.
Request permission to inform emergency
monitoring team (CATT) and/or family.
Consult with supervisor as necessary.
Limit confidentiality.
Immediately refer to hospital mental
health services or emergency mental
health team.
Call ambulance/police if necessary.
Obtain support from supervisor if
required.
•
•
•
•
High risk: thoughts, previous attempts, risk
factors, clear and detailed plan, immediate
intent to act, means are available (and lethal),
social isolation.
•
•
•
•
•
Source: Lee, et.al., 2007.
Section 3: Self reporting questionnaire (SRQ)
The SRQ was developed by the World Health Organisation to screen for symptoms of the more
common high prevalence mental health problems, such as anxiety and depression, among clients in
primary care settings. There are 20 questions related to common symptoms of depression, anxiety
and somatic complaints (such as sleep problems, headaches and digestive problems).
The client is first asked to tick any symptoms that they have experienced in the past 30 days. For
every ‘yes’ answer, the client is asked to tick whether they have experienced that problem when
they were not using alcohol or other drugs. The clinician then counts the total number of ticks in the
Page 26
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
circles and places the score at the bottom of the page. Scores should be interpreted on Section 3:
Self Reporting Questionnaire of the PsyCheck as indicated in Table 2. The actions recommended are
to be considered as an adjunct to usual practice.
The PsyCheck Screening Tool is the basis of a stepped care model in which the treatment response is
contingent upon the initial PsyCheck Screening Tool score. Table 2 outlines the incremental
responses recommended and the PsyCheck Clinical Treatment Guidelines outline the specific
intervention. PsyCheck screening materials, including a user’s guide with details of administration
and scoring, are available through the Australian Government Department of Health and Ageing
(www.health.gov.au).
Table 2. Interpretation of the SRQ score
Total score on SRQ
Interpretation
Action
0*
No symptoms of depression,
anxiety and/or somatic complaints
indicated at this time
•
1-4*
Some symptoms of depression,
anxiety and/or somatic complaints
indicated at this time
•
Considerable symptoms of
depression, anxiety and/or
somatic complaints indicated at
this time
•
5 or above*
•
•
•
•
Re-screen using the PsyCheck
Screening Tool after 4 weeks
if indicated by past mental
health questions or other
information
Offer Session 1 of the
PsyCheck Brief Intervention
Provide self-help material
Re-screen using the PsyCheck
Screening Tool after 4 weeks
Offer Sessions 1–4 of the
PsyCheck Brief Intervention
Re-screen using the PsyCheck
Screening Tool at the
conclusion of 4 sessions
If no improvement in scores
evident after re-screening,
consider referral
*Regardless of the client’s total score on the SRQ, consider referral if significant levels of distress are present.
Source: Lee, et.al., 2007
Screening for psychosis
Florid psychotic symptoms are usually easy to identify. However, methamphetamine users may
present with a range of low grade psychotic symptoms that are unusual but more difficult to identify
(Lee, et.al., 2007). These may include:
· Paranoia: suspicions about treatment, friends or acquaintances, such as other people
plotting to harm them.
· Delusions: extreme beliefs that are unsupported by evidence, such as feeling invincible or a
belief that someone is trying to contact them through the television.
• Hallucinations: seeing, hearing, smelling or feeling things that other people cannot (Lee,
et.al., 2007).
Often methamphetamine users report tactile hallucinations, such as bugs or ants crawling under
their skin. People may also report hearing voices or seeing things out of the corner of their eye. The
most effective way of uncovering these symptoms is through the clinical interview. It is important
© Lynne E. Magor-Blatch & James A. Pitts
Page 27
Group Intervention for Amphetamine-Type Stimulants (GIATS)
that the client feels comfortable enough to disclose symptoms. This is particularly important within
the context of the TC, where the person may be interacting with many people, rather than a few
clinicians or medical staff. The environment may therefore be overwhelming.
It is therefore important that staff working with the client ask for information in a way that indicates
that they understand the symptoms and reflect feelings back appropriately without reinforcing these
symptoms (for example: 'that must make you feel scared') (Lee, et.al., 2007).
The Psychosis Screener is an instrument which has been developed to measure psychotic symptoms.
It may be useful as an adjunct to the clinical interview (see Work sheet 3: Psychosis screener). If you
are unsure about how to assess for psychotic symptoms, consult with your local mental health
service.
Page 28
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Section 2:
Tip Sheets
© Lynne E. Magor-Blatch & James A. Pitts
Page 29
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Page 30
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 1: Dose effects of amphetamines
Low dose
Physical
Psychological
High dose
· Increases in systolic and
diastolic blood pressure
· Sweating
· Palpitations
· Chest pain
· Shortness of breath
· Headache
· Tremor
· Hot and cold flushes
· Increases in body temperature
· Reduced appetite
· Euphoria
· Elevated mood
· Sense of wellbeing
· Increased alertness and
concentration
· Reduced fatigue
· Increased talkativeness
· Improved physical performance
·
·
·
·
·
High blood pressure
Rapid or abnormal heart action
Seizures
Cerebral haemorrhage
Jaw clenching and teethgrinding
· Nausea, vomiting
· Confusion
· Anxiety and agitation
· Performance of repetitive
motor activity
· Impaired cognitive and motor
performance
· Aggressiveness, hostility and
violent behaviour
· Paranoia including paranoid
hallucinations
· Common delusions including
being monitored with a hidden
electrical device, and
preoccupation with ‘bugs’ on
the skin
Effects of methamphetamine use
Positive effects
·
·
·
·
·
·
Euphoria
Increased libido
Alertness
Diminished appetite
Enhanced reflexes
Feelings of confidence and physical
strength
Negative effects
·
·
·
·
·
·
·
·
·
·
© Lynne E. Magor-Blatch & James A. Pitts
Increased heart rate and irregular heart
beat
Abdominal pain
Sweating
Dilated pupils
Fatigue
Parasitosis (picking and scratching skin)
Agitation, anxiety and paranoia
Confusion, disorientation and
hallucinations
Psychosis
Violent and aggressive behaviour
Page 31
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 2: Managing acute toxicity
While admissions into treatment will occur after the detoxification period, some agencies also
include withdrawal services as part of their overall service provision. These may be stand-alone
services, or part of a continuum of services whereby the person moves into the treatment phase
on conclusion of detoxification. Information gathered from the consultations also indicates some
clients will present with symptoms after detoxification, and in some cases symptoms will emerge
after admission to the treatment setting. Recognising and responding to potentially toxic
presentations can be challenging. The following information is outlined by Lee and colleagues
(2007) in Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No 14: Methamphetamine
dependence and treatment.
Step 1: Observe clinical signs of toxicity
As reaction to the amount of drug ingested will vary between individuals, clinical observation of
toxic signs is more important than attempting to determine the amount ingested. Some
individuals may experience these symptoms after relatively low doses of methamphetamine.
Symptoms which may alert clinicians to potential toxicity include:
· Chest pain
· Rapid increase in body temperature
· Psychotic features (such as hallucinations, paranoia or delusions)
· Behavioural disturbances which may put the individual or others at risk
· Seizures
· Uncontrolled hypertension (Lee, et.al., 2007).
Step 2: Monitor vital signs
·
Check temperature and pulse
Step 3: Attempt verbal de-escalation of the situation if required
·
·
·
·
Talk quietly and calmly to the person
Do not raise your voice or become agitated
Take the person to a quiet place where there are no distractions or potential weapons
If acute behavioural disturbance is a feature of toxicity, reliance on physical restraint is not
recommended and may worsen the situation
In some cases the client may need to be readmitted to hospital or withdrawal services for a
period of time in order to stabilise or to manage withdrawal or mental health symptoms. Once
the person is stable and medical, mental health and medication needs assessed and addressed, it
is likely that they will be able to return to the treatment setting to recommence treatment.
Page 32
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 3: Managing aggressive or agitated behaviour
Many TCs in the consultation phase noted that some methamphetamine and other ATS users will
experience an increase in aggressive behaviour as a consequence of their methamphetamine and
other ATS use. It is important for all staff and clients are clear about the safety procedures and
appropriate responses in managing clients who may, from time to time, present in an agitated or
aggressive state. Discussion with all members of the treatment program, including staff and
clients, is important in developing effective responses to these possible situations. Regular
training, which includes role plays, can be invaluable in effectively responding and ensuring the
safety of the client, staff and others in the vicinity (Lee, et.al., 2007).
Behaviours associated with agitation that may become a concern include:
• pacing
• being unsettled
• paranoia/suspiciousness
• delusions (persecutory or grandiose)
• argumentative with little or no provocation
• easily upset over trivial things
• threatening others
• dissatisfied with everyone
• offering unwarranted criticism
• criticising surroundings
• condemning staff of inadequate sensitivity, training or qualifications
• claiming that everyone is out to make things difficult for them
• feeling unsupported
It is important to understand that the person’s judgement may be impaired and therefore their
experience may not be the same as yours or others within the treatment service. Therefore, while
it is important to maintain the overall essence of the treatment program in all clinical work, at
times the way in which rules are implemented may need to be evaluated. When responding to
difficult behaviours such as these, it is important to remain aware that this may be an indicator of
the presence of psychotic behaviour that may make the person a risk to themselves or others.
• Keep your voice low and controlled
• Listen to the person
• Avoid insincerity, ridicule or smiling
• Avoid taking their behaviour personally
• Explain to the person what is happening, what you are doing and why you are doing it
· Avoid movements or actions which may be perceived as threatening, such as quick
movements or moving towards the person suddenly
• It is essential that you consider your own occupational health and safety at all times
· Where possible, manage the physical environment so that you are able to leave if
necessary
• Make sure you advise others if you are about to enter a high-risk situation
• In the case of extreme agitation or aggression, the escalating threat of physical injury
to the client, yourself or others will make it necessary to take more immediate action
• Follow protocols appropriate to your organisation and request police or emergency
service attendance if appropriate (Lee et al., 2007).
© Lynne E. Magor-Blatch & James A. Pitts
Page 33
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 4: Some facts about Cravings
(Adapted from Marlatt & Gordon, 1985 and Lee, et.al., 2007)
1. Cravings/urges to use are a natural part of modifying drug use. This means that you are no
more likely to have any more difficulty in altering your speed use than anybody else does.
Understanding cravings helps people to overcome them.
2. Cravings are the result of long-term use and can continue long after quitting. So people
with a history of heavier use will experience stronger urges.
3. Cravings can be triggered by people, places, things, feelings, situations or anything else that
has been associated with using in the past.
4. Think of a craving in terms of a wave at the beach. Every
wave/craving starts off small, and builds up to its highest point,
and then it will break and flow away. Each individual craving
rarely lasts beyond a few minutes.
5. Cravings will only lose their power if they are NOT
strengthened (reinforced) by using.
6. Using occasionally will only serve to keep cravings alive.
That is, cravings are like a stray cat – if you keep feeding it, it
will keep coming back.
7. Each time a person does something rather than use in response to a craving, the craving
will lose its power. The peak of the craving wave will become smaller, and the waves will
be further apart. This process is known as extinction.
8. Abstinence is the best way to ensure the most rapid and complete extinction of cravings.
9. Cravings are most intense in the early parts of quitting/cutting down, but people may
continue to experience cravings for the first few months and sometimes even years after
quitting.
10. Each craving will not always be less intense than the
previous one. Be aware that sometimes, particularly in
response to stress and certain triggers, the peak can return to
the maximum strength but will decline when the stress
subsides.
Taking this a bit further. Think of riding the waves as Urge
surfing – going through the experience of craving without
‘fighting’ the experience.
Focusing attention on the feelings and sensations and recording the intensity of cravings
before and after the peak will help in gaining a sense of control over the experience.
Page 34
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 5: Drug treatment metaphor
(Adapted from Hermann Meyer, 2007)
People get into drug use for all kinds of reasons. You can compare it to getting into boating. At first
you are given free rides and you like it. Then you get your own boat and you enjoy your trips. But
soon you find yourself adrift at sea attacked by pirates. You have to seek shelter in a shark infested
archipelago, full of reefs, sandbanks, rocks and dangerous currents and things get really unpleasant
and very scary.
The sensible thing to do now is to throw in your anchor (which is a
good metaphor for seeking help). You might do this to start off by
going onto a pharmacotherapy program, doing some counselling,
going into detox or doing some meetings. These are all good
starts, and although you might still be in the same
territory, for now you have steadied the boat and you
are safe from running aground, drowning and being
eaten by sharks.
Remember, at this point there is nothing wrong with
that sea anchor. You might want to pull it up and go on your way, but getting stabilised
first is a good thing. You are not making any progress by setting yourself adrift again in those
dangerous waters. In this situation the anchor is not your problem, it is your salvation.
But over time you will want to move on. Maybe it’s getting too hard bobbing on the ocean, not
really moving in any direction. So you think about where to go from here, looking for a safe
direction and a worthwhile goal.
Once you have made up your mind where you want to go, you plot a
course out of the treacherous waters. Lifting the anchor free to
move towards the goals you have chosen according to your deeply
held values.
Maybe it’s time to start to look at some of the reasons for your drug
use? Maybe some of the other things that have been going on in
your life could do with some attention?
Makes sense?
© Lynne E. Magor-Blatch & James A. Pitts
Page 35
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 6: Pavlov’s Dog
Ivan Pavlov was a Russian scientist who was born in 1849 and died in
1936. His work was actually about understanding the way in which the
digestive system worked. We all probably know the story. When a dog
is given food, saliva starts to pour from the salivary glands in its mouth.
This saliva is needed in order to make the food easier to swallow
because it contains enzymes that break down the food. The same thing
happens in humans.
Pavlov became interested when he saw that the dogs drooled even
when the food wasn’t around. Although no food was in sight, their
saliva still dribbled. It turned out that the dogs were reacting to white lab coats. Every time the
dogs were served food, the person who served the food was wearing a white lab coat. Therefore,
the dogs reacted as if food was on its way whenever they saw a white lab coat.
Pavlov then tried to figure out why this happened by doing a number of experiments. For example,
he rang a bell when the dogs were fed. If the bell was sounded at the same time as the food was
given to them, the dogs learnt to associate the sound of the bell with food. After a while, just at
the sound of the bell, the dogs began drooling. After a while, Pavlov stopped giving the dogs food
when the bell was rung. For a little while, they kept salivating. But then, even if the bell was rung,
when no food followed, the dogs stopped salivating – this is called extinction.
We call this process Conditioned Learning, and an important principle is that a response that we
have been conditioned to, or taught, (salivating in the case of the dogs) becomes less intense if the
stimulus (the bell in this situation) is repeated but without any reward (food).
Nowadays, this knowledge has also been exploited by commercial
advertising. What happens when you see a particular product
advertised on TV or on a billboard? Seeing an image or just hearing the
music starts us thinking – the Toohey’s music, ads that tell us that if we
want to be attractive, or get the right girl or boy, we have to wear a
particular product or look a particular way. The objective is to train
people to make the ‘false’ connection between positive emotions (e.g.,
happiness or feeling attractive) and the particular brand of product.
We also use this process to desensitise to particular things – like fear of
spiders or fear of flying, by using techniques, such as muscle relaxation
and imagining the fear-producing situation while trying to reduce the person’s anxiety by
relaxation.
Now think about it from your own perspective. Conditioning forms the basis of many things which
you have learned over the years – both positive and negative. What are some of the things you
can associate with this process? What happens when you hear certain songs, advertisements
coming on the TV, the sound of the dinner bell or someone announcing a group is being called?
What are the feelings associated with this and where do you experience them?
When you were using, what happened when you went to certain places, met up with certain
Page 36
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
people? Even if you had made a commitment not to use, going to places that triggered old
behaviours meant that you sometimes fell right back into them.
So one of the things you can do is not go to those places, not turn on the TV or listen to music that
might trigger thoughts again. Or you can change your response by starting to change the reward
system.
This might mean still going to the city or places which used to trigger thoughts of using, but this
time change the reward system by going to a meeting or catching up with clean friends for a
coffee. So gradually, even though the trigger is still there, you change the reward system.
Over time, when you think of these places, hear the music, see people, you will have a different
reward system that has become part of your life. You can change the way you react to things and
the way you live your life.
© Lynne E. Magor-Blatch & James A. Pitts
Page 37
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 7: The Bridge Concept
(Adapted from the Ley Community, UK)
This concept illustrates how it is possible for people to overcome their problems and to get back into
the mainstream of society by addressing their issues and substance use.
Remember the way you were when you were on the scene; you'll probably have belonged to one of
the groups on the left of the picture. If you were involved in drugs then you obviously knew a lot of
people on the drug scene. And the same with crime, you probably knew a lot of scams, especially if
you ended up in gaol. Well, the members of these groups had one thing in common, they knew how
to relate to each other because they were part of the same scene. However, it’s possibly true that
most of the contact they had was negative and they may never really have known how to relate on a
meaningful level.
Detox,
starting to
feel a bit
better
Before starting
treatment - other
drug users,
offenders, the
‘scene’
Into treatment and ‘doing the
program’ - not sure about it – but I’ll
give it a go.
I’m ‘stepping‘ my way through,
getting more supports and moving
from one stage to the next.
Continuing care –
supported
accommodation –
Back into work or study
My new life Family, friends,
work, study and
involved as a
member of the
community
Maybe you wondered why you felt different to other people. Why you had to take drugs or alcohol,
why you gambled and couldn't stop. Why you couldn't keep out of gaol for very long. Why you
couldn't just be like everybody else, like the people on the other side of the bridge.
Well, until you reached here you may never really have found out the answers although you
probably tried many times. Maybe there was no-one around to really help you? If you can imagine
that there is a bridge in between the groups walking one way on the left, and the others on the right
walking in the opposite direction, then ask yourself this question, "How many times have I tried to
cross the bridge, get a job and get myself together?"
Page 38
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
The answer is that you probably tried many times. Remember the times when you tried various
'cures'. Or saying to yourself in gaol that you're never going to get into any trouble again. Or just
trying to go straight for the sake of it, or maybe even for a girlfriend/boyfriend or family. Whatever
it was, sometimes when you tried to get yourself back on your feet again it was OK for a bit, but then
it failed.
Maybe it worked for a while, and that’s OK, because maybe you were able to make some changes,
look after your health, change some of the ways you used, so that you didn’t do as much harm to
yourself or those around you.
Maybe you felt there was still something missing, but you didn't really know what it was, especially if
you kept ending up in trouble, or your life just kept spiralling down. And so now you are here in this
program.
We are like a bridge, a bridge back to life - hence the name - Bridge Concept.
You’ve made a start – got through detox and now you are in the first stage of treatment on the
recovery path. Going over the bridge is a bit like stepped-care, so you ‘step’ your way through it –
there are different stages and different things you will do and learn along the way.
As you progress on the recovery path you will learn things about yourself, make new friendships and
gain new skills. This is all part of the journey.
The important thing is that you are on the bridge and one day when you look back on it,
you’ll realise –
“I crossed the Bridge!”
© Lynne E. Magor-Blatch & James A. Pitts
Page 39
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 8: Managing your Feelings in Recovery
The National Institute on Drug Abuse (NIDA) has identified the following eight steps to help
understand and manage feelings to reduce the chance of using cocaine or other substances. These
steps are useful for everyone, regardless of the specific feeling that they are dealing with or the
substances which have been used. These steps equally apply to ATS use.
Step 1: Recognise and label your feelings.
Don’t deny your feelings because doing so can cause you difficulty in the long run. Even if you feel
what you believe is a negative or bad feeling, remember that it is simply an honest feeling. Feeling
an emotion doesn’t mean you have to act on it.
You can also look for patterns in regard to your feelings. Do you tend to experience certain feelings
much more frequently than others? For example, are you prone to feeling anxious and worried
when things aren’t going your way, or when you have to go to certain places or see certain people?
Step 2: Be aware of how your feelings show.
Pay attention to how your feelings are reflected in your body language, physical changes, thoughts,
and behaviour. These are clues you can use to become more aware of your feelings. For example,
pacing and feeling “keyed up” or “tight” may indicate that one person is angry. For another person,
this behaviour may indicate feeling worried. A person may be prone to headaches or other physical
complaints when upset and angry. These or other physical cues may be signs that something is
going on that needs your attention.
When feeling upset, rejected, or frustrated, one person may be prone to going on mini-shopping
sprees. Another may turn to food and eat too much. Another person may withdraw and avoid other
people when he or she is upset. The ways in which feelings are expressed through behaviour are
endless. Your behaviours can also tell you something important about your feelings.
Step 3: Look for causes of your feelings.
Feelings aren’t usually caused by other people or events, but by how you think about them. Your
beliefs about feelings play a big role in how you deal with them. For example, if you believe anger is
bad and should not be expressed, you are likely to deny angry feelings or keep them to yourself.
To understand why you feel the way you do, look at the connections among what you believe or
think, how you feel, and how you act. Any of these components can affect another.
Step 4: Evaluate the effects your feelings and your coping style have on both yourself and other
people.
How is your physical or mental health affected by your feelings? How is your behaviour,
relationships with others, or self-esteem affected? If your emotions or the ways in which you cope
with them cause you distress or problems in your relationships with others, you need to work on
changing how you deal with the feelings. You need to consider how your emotional states and your
related behaviour affect others as well as yourself.
For example, if you are depressed or angry, how does this affect your family? If you get irritated and
snap at others when you are depressed, how does this affect them?
Page 40
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Your emotions and the way in which you cope with them may have many positive effects. Most
likely, some feelings have, more or less, a positive effect on your life, and some have more of a
negative effect on your life. If a feeling or how you deal with it causes problems for you, this is a
signal that you should consider making some type of change.
Step 5: Identify coping strategies to deal with your feelings.
Continue to use old coping methods if they are effective. However, you can learn new coping
methods, if needed. There is no right way to cope with your feelings. How you cope depends on the
specific situation you are in. Having a variety of coping strategies puts you in a good position to
effectively deal with your feelings without using alcohol or other drugs.
Step 6: Rehearse or practice new coping strategies.
Practicing the way in which you might deal with a feeling, especially when another person is
involved, can make you feel more prepared and confident about what you will say. Learning to
express feelings appropriately is a skill that has to be learned and practiced just like any other skill.
Sometimes you can practice by yourself by thinking of different things that you can say in certain
situations. You can even practice how you might deal with your feelings toward another person in a
given situation by rehearsing what you could say out loud.
You also can practice with another person. For example, if you feel very attracted to a person with
whom you work and want to ask this person out on a date but feel uncomfortable doing so, you can
practice with a friend or family member. If you are upset and angry with a family member, work
with someone else to practice different ways of sharing your feelings directly.
Step 7: Put your new coping strategies into action.
You can come up with a plan to deal with feelings, but if you don’t put your plan into action, it does
little good. Action is needed for change. You have to translate your desire or need to change, into a
behaviour. Don’t worry about making a mistake as this is to be expected when you first change how
you cope with your feelings.
Step 8: Change your coping strategies based on your evaluation of whether these strategies were
effective.
All strategies will not work the same in all situations. The key is having several coping strategies to
rely on so that you don’t use the same strategy all of the time. Even if a coping strategy works well
in one situation, it may not work in another. Make sure you have several strategies to help you cope
with your feelings.
© Lynne E. Magor-Blatch & James A. Pitts
Page 41
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 9: The Fight or Flight Response
The ‘fight or flight response’ is our body's primitive, automatic,
inborn response that prepares the body to ‘fight’ or ‘flee’ from
perceived attack, harm or threat to our survival.
What happens to us when we are under excessive stress?
When we experience excessive stress—whether from internal
worry or external circumstance—a bodily reaction is triggered,
called the ‘fight or flight’ response. This response is hard-wired into our brains and represents a
genetic wisdom designed to protect us from bodily harm. This response actually corresponds to an
area of our brain called the hypothalamus, which—when stimulated—initiates a sequence of nerve
cell firing and chemical release that prepares our body for running or fighting.
When our fight or flight system is activated, we tend to perceive everything in our environment as a
possible threat to our survival. By its very nature, the fight or flight system bypasses our rational
mind—where our more well thought-out beliefs exist—and moves us into ‘attack’ mode. This state
of alert causes us to perceive almost everything in our world as a possible threat to our survival. As
such, we tend to see everyone and everything as a possible enemy. We may overreact to the
slightest comment. Our fear is exaggerated. Our thinking is distorted. We see everything through
the filter of possible danger. We narrow our focus to those things that can harm us. Fear becomes
the lens through which we see the world.
What is our fight or flight system designed to protect us from?
Our fight or flight response is designed to protect us from the proverbial sabre tooth tigers that once
lurked in the woods and fields around us, threatening our physical survival. At times when our
actual physical survival is threatened, there is no greater response to have on our side. When
activated, the fight or flight response causes a surge of adrenaline and other stress hormones to
pump through our body.
When we face very real dangers to our physical survival, the fight or flight response is invaluable.
Today, however, most of the sabre tooth tigers we encounter are not a threat to our physical
survival. Today’s sabre tooth tigers consist of rush hour traffic, missing a deadline or having an
argument with our boss or partner. Nonetheless, these modern day sabre tooth tigers trigger the
activation of our fight or flight system as if our physical survival was threatened. On a daily basis,
toxic stress hormones flow into our bodies for events that pose no real threat to our physical
survival.
In most cases today, once our fight or flight response is activated, we cannot flee. We cannot fight.
We cannot physically run from our perceived threats. When we are faced with modern day, sabre
tooth tigers, we have to sit and ‘control ourselves.’ We have to sit in traffic and ‘deal with it.’
However, many of the major stresses today trigger the full activation of our fight or flight response,
causing us to become aggressive, hypervigilant and over-reactive. This aggressiveness, overreactivity and hypervigilance cause us to act or respond in ways that are actually counter-productive
to our survival. This leads to a difficult situation in which our automatic, predictable and
unconscious fight or flight response causes behaviour that can actually be self-defeating and work
against our emotional, psychological and spiritual survival.
To protect ourselves today, we must consciously pay attention to the signals of fight or flight
To protect ourselves in a world of psychological—rather than physical—danger, we must consciously
pay attention to unique signals telling us whether we are actually in fight or flight. Some of us may
Page 42
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
experience these signals as physical symptoms like tension in our muscles, headache, upset
stomach, racing heartbeat, deep sighing or shallow breathing. Others may experience them as
emotional or psychological symptoms such as anxiety, poor concentration, depression,
hopelessness, frustration, anger, sadness or fear.
Excess stress does not always show up as the ‘feeling’ of being stressed. Many stresses go directly
into our physical body and may only be recognised by the physical symptoms we manifest.
What can we do to reduce our stress and turn down the activity of our fight or flight response?
The fight or flight response represents a genetically hard-wired early warning system—designed to
alert us to external environmental threats that pose a danger to our physical survival. Because
survival is the supreme goal, the system is highly sensitive, set to register extremely minute levels of
potential danger. As such, the fight or flight response not only warns us of real external danger but
also of the mere perception of danger. This understanding gives us two powerful tools for reducing
our stress. They are:
i.
Changing our external environment (our ‘reality’). This includes any action we take that
helps make the environment we live in safer. Physical safety means getting out of toxic,
noisy or hostile environments. Emotional safety means surrounding ourselves with
friends and people who genuinely care for us, learning better communication skills, time
management skills, getting out of toxic jobs and hurtful relationships. Spiritual safety
means creating a life surrounded with a sense of purpose, a relationship with a higher
power and a resolve to release deeply held feelings of shame, worthlessness and
excessive guilt.
ii.
Changing our perceptions of reality. This includes any technique whereby we seek to
change our mental perspectives, our attitudes, our beliefs and our emotional reactions
to the events that happen to us.
© Lynne E. Magor-Blatch & James A. Pitts
Page 43
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 10: Coping With Anxiety: Bodily Symptoms
Light headedness
Tiredness
Difficulty in sleeping
Headaches
Mind racing
Sweating
Dry mouth
Tension
Blurry vision
Feeling breathless
Breathing fast or shallow
Sweating or shivering
Difficulty in swallowing
Choking sensation
Heart racing
Palpitations
Chest pains
Jelly-like legs
Shaking
Trembling
Restless
Pins & Needles
Wanting to run
Page 44
Stomach pains
Nausea
Lack of appetite or craving for food
Butterflies in the tummy
Bladder weakness
Diarrhoea
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 11: (Changing) The Anxiety Cycle
Intervention:
Re-evaluate, “It
didn’t go well this
time, I can change
that”. Practice
anxiety-reduction
techniques, positive
self-talk.
Restructuring of
thoughts & beliefs
to change pattern
Longheld
heldbeliefs
beliefs about
about being
Long
beingno
no
good
in social
situations,
“I’m a poor
good
in different
situations,
mixer”,
“I justmixer”,
can’t talk
people”.
“I’m a poor
“I to
just
can’t
talk to people”.
After the event:
Catastrophic
interpretations
Avoid situations,
“I can’t make it”.
Before the
event:
Internal,
external,
symbolic &
unconscious
TRIGGERS
Negative thoughts, “I looked
stupid, I didn’t cope”. “Am I
going to get into trouble, Will
I get a complaint?”
Negative automatic
thoughts, “I’m not going
to cope”. “How am i
going to deal with this
when I get there?”
Social
A n xi e t y
Safety behaviours –
e.g., avoids eye
contact, keeps
busy, sits away
from others
Intervention:
Breathing
Grounding
Self-soothing
talk to change
pattern and
help cope with
feelings of
anxiety
“I’m OK”
Strengthen
negative
beliefs
Physical
symptoms –
tense, heart
palpitations
etc
During the
event
Increased
physical
symptoms –
sweating,
tense
© Lynne E. Magor-Blatch & James A. Pitts
Focus on
self,
“I’m looking
stupid”, “I’m
sweating”.
“Does it look
OK, did I do
it right?”
Intervention:
Breathing
Grounding
Self-soothing
talk to change
pattern and
help cope
with feelings
of anxiety
“I can do this”
Page 45
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 12: Ten Most Common Relapse Dangers & High-Risk Situations
1.
Being in the presence of drugs, drug users, or places where you used to “score” drugs or use.
2.
Negative feelings, particularly anger, sadness, depression, loneliness, guilt, fear and anxiety.
3.
Positive feelings that make you want to celebrate.
4.
Boredom.
5.
Getting stoned on any drug, including alcohol.
6.
Physical pain.
7.
Listening to drug use stories and dwelling on using.
8.
Suddenly having a lot of cash.
9.
Using prescription drugs that affect you, even if you use them properly.
10. Believing that you are finally recovered, that none of the above situations nor anything else
stimulates you to crave drugs and that, therefore, it’s safe for you to use occasionally.
High-risk situations are those that threaten your recovery or trigger a strong craving to use. These
are situations that remind you of using or that cause you to feel like you want to use drugs because
others pressure you to do so. Upsetting emotions, serious conflicts with people, and difficult life
problems are other potential high risk factors that can increase your vulnerability to relapse. It is
your ability to use your plan to cope with your high-risk situations that ultimately determines
whether you stay drug free.
·
·
·
An example of a high-risk situation is going to a party where people are using. This might
make you feel like you want to use too, especially if you used to enjoy these kinds of social
functions.
Another example of a high-risk situation is a family get-together where alcohol and other
drugs are available or at which stressful family interactions such as arguments occur. It is
helpful to identify the particular situations that are likely to put you at risk for using before
you actually face these situations. You can then develop a plan to avoid them, if possible, or
deal with them so that you don’t use. Your plan may involve going to meetings, talking to
your sponsor or a supportive friend, engaging in some physical activity, assertively refusing
substance use offers, changing your social habits, or actively planning social activities in nonthreatening environments.
Talking to others in recovery about their dangerous situations and how they cope with them
can be useful. Their ideas may help you develop strategies that will help you deal with your
own high-risk situations.
Page 46
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Section 3:
Treatment Modules
© Lynne E. Magor-Blatch & James A. Pitts
Page 47
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Page 48
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Group Intervention for Amphetamine-type Stimulant use (GIATS)
This section has been developed after bringing together information from a number of sources. This
includes adaptation of some materials from the brief intervention developed for methamphetamine
users (Baker et al., 2003; Baker et al., 2004), information from the Methamphetamine Dependence
and Treatment Practice Guidelines, developed by Dr Nicole Lee and colleagues (2007), and
information and exercises from Acceptance and Commitment Therapy (ACT), developed by Dr Russ
Harris; Motivational Interviewing with Groups, developed by Dr Chris Wagner and MindfulnessBased Cognitive Therapy, developed and presented by Liana Taylor. Training in Acceptance
Commitment Therapy with Russ Harris, Motivational Interviewing with Groups with Chris Wagner
and Mindfulness-Based Cognitive Therapy with Liana Taylor was undertaken by the principal author
prior to the development of the Treatment Protocol. This training reinforced the belief that all TC
staff and clinicians engaged in using any of these techniques should firstly undertake the necessary
training before using the materials. This is particularly important when utilising Mindfulness
techniques, since clients with mental health problems may be susceptible to re-traumatisation. In
the hands of the untrained, it is possible that some techniques will create further distress.
The Brief Intervention developed by Dr Amanda Baker and colleagues (Baker et al., 2003; Baker et al.
2004), is based on motivational interviewing and cognitive behaviour therapy. Results of the trial of
this intervention (Baker et al., 2004) suggested that two or four sessions are effective in increasing
abstinence among regular methamphetamine users. The authors state the four-session intervention
should be offered with stepped care principles in mind. The treatment manual for this intervention
may be downloaded from www.health.gov.au.
The GIATS is divided into seven modules which may be utilised flexibly in the pre-treatment stage or
in the first stage of treatment. It addresses issues of craving, building motivation to change and
strengthening commitment. It recognises that although the client has made a commitment to enter
treatment, their continuation within a treatment program may be influenced negatively by a
number of factors, including removal from the drug scene and possible harm, relaxation of family
and court pressure and, very importantly, the loss of coping mechanisms – i.e., the drug use which
has previously assisted the person to cope with the things with which they are unable to cope.
The following modules are provided as part of the treatment package. The first two modules are
aimed at clients who are in the pre-treatment or very early treatment stage, and address motivation
for change and understanding and dealing with the cravings which may continue for some time in
the initial program phase. Module 3 commences the CBT and ACT training. Depending on the point
of introduction, the Treatment Protocol can be used with some flexibility. For example, the first two
modules might be used with clients at pre-treatment on an individual or group basis.
Group work within the TC or other treatment setting might commence with Module 1, but could also
commence with Module 3 if the first two modules have already been presented at pre-treatment.
Similarly, the final module, Relapse Prevention, may form part of the complete protocol, or be left
aside until post-discharge or be used as the third module in an outpatient setting.
Module 1: Building motivation for change
Module 5: Learning how to deal with anxious
Module 2: Understanding and coping with cravings
thoughts and feelings
Module 3: How thoughts influence behaviour
Module 6: Understanding and acknowledging
Module 4: Understanding feelings: Mind/Body
core beliefs and values
connection
Module 7: Relapse Prevention
© Lynne E. Magor-Blatch & James A. Pitts
Page 49
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Trial of the GIATS: First Study
As a result of the first trial of the Treatment Protocol with Mirikai in Queensland and Cyrenian House
in Western Australia, some changes have been made to the materials and the presentation. The
prime concern expressed by participants and facilitators was that there were too many materials
provided for each session – therefore sessions were lengthening out. This was impacted on further
where homework tasks were not completed in the time between sessions and were therefore
undertaken and processed at the commencement of each session.
Therefore some of the materials have been changed, the wording of the Pavlov’s Dog worksheet
(Module 2) has been changed considerably and has become a Tip Sheet and other activities (e.g.,
The Raisin Exercise in Module 3) are provided as suggested activities, but may be replaced by others
(e.g., the Floating Leaves on a Moving Stream exercise could replace The Raisin Exercise). The
purpose of The Raisin Exercise had been to reduce stress by slowing participants down and to bring
their awareness into the present – it is a Mindfulness exercise which can be useful in helping people
who have become cut off from their senses to be more in touch. However, its use must be a
judgement call for the group facilitator. Some people found it difficult to approach the exercise
mindfully and therefore were not able to get the value from the task. Others rated the exercise as
one of the things they most liked about the module.
The way in which Tip Sheets are used is also up to the group facilitator and the program. Different
facilitators used them differently in the trial, some providing the Tip Sheets with little explanation,
while others read through and processed the information with participants. The value to
participants of discussing and processing the information was evident in the evaluations. However,
another approach is to use the Tip Sheets independently of the session in a Concept Group or other
forum during the time between groups to reinforce the learning. As an example, The Bridge Concept
(Module 2) has been used in its original form by many TCs since the 1970s.
The version here has been adapted as the original version was specific to the program (e.g., The Ley
Community in the UK). Therefore the points of progress related to that program’s stages. For TCs
that conduct concept groups, The Bridge Concept and other metaphors contained in the Treatment
Protocol are useful additions to materials. In the context of the Treatment Protocol, The Bridge
Concept, Some facts about Cravings, Drug Treatment Metaphor and other Tip Sheets could be used
in this way. This would reinforce the materials from the module and could become the ‘homework
task’. Therefore at the end of each module, suggestions have been provided as to how materials
might be used in the time between sessions – hence The Bridge Concept, Pavlov’s Dog or the Drug
Treatment Metaphor might be used in a concept group between Modules 1 and 2 and then
discussed in Module 2.
One suggestion coming from the evaluation was to present all the information pertaining to the
module within the unit material – i.e., Tip Sheets and Worksheets included into the module’s
materials, rather than in separate sections within the training manual. While this may make the
presentation of the modules somewhat easier, the concern was that this would in fact work against
a flexible use of materials – e.g., the flexible use Tip Sheets in the TC and as information sheets for
staff, family members and others to help them better understand some of the issues which their
family member might be experiencing. However, the order of sections has changed, so that Clinical
Assessment is now Section 1, Tip Sheets (which may be used independently of the Treatment
Modules) are in Section 2 and Sections 3 (Treatment Modules) and 4 (Worksheets) remain the same.
At the commencement of each module outline, there is a list of materials needed for that module.
Facilitators do need to read through this list, to prepare for the group – including photocopying the
Page 50
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheets and Worksheets necessary for the number of participants in the group, but it is hoped
that the presentation of the manual in this current form will assist in this task.
Evaluation of the GIATS: Outcome study
We are grateful to the participants and facilitators at Mirikai and Cyrenian House for trialling the
original materials, and thereby contributing to the development of the treatment protocol, which
was then further evaluated through study undertaken with 12 TCs in Australia between 2009 and
2013. These TCs included: Goldbridge, WHOS Najara and Logan House in Queensland; Odyssey
House, WHOS Rozelle, WHOS Hunter and Selah Farm in New South Wales; Karralika and Canberra
Recovery Service in the Australian Capital Territory; Palmerston Farm and Cyrenian House in
Western Australia; and Odyssey House in Victoria.
The evaluation of the GIATS was undertaken through a quasi-experimental study that assessed
outcomes for ATS users accessing treatment in 12 Australian TCs and included participants who
received the intervention in five sites (n=125; 83 males and 42 females) compared with treatment as
usual (TAU) in seven matched sites (n=122; 75 males and 47 females). Participants were interviewed
and completed self-report questionnaires of psychosocial measures at T1 (baseline: Time 1) entry to
the study and at two follow-up points over 18 months. Results provided an important profile of ATS
users, describing their severity of dependence, history of lifetime and current substance use, and
severe symptomatology on mental health and psychosocial measures.
Results at T2 (six-eight months post-baseline) on measures of metal health and wellbeing showed
both groups significantly improved over baseline, with the Intervention group showing greater
statistical and clinical improvement from baseline when compared with TAU participants. Results for
both groups at T3 (second follow-up: 12-18 months post-baseline) showed statistically significant
and clinical improvement over baseline on a number of measures.
While statistically significant differences were found between groups at T3 in only one area - an
improvement on one of the measures of executive functioning (Self-Monitor), participants
significantly improved from baseline on measures of mental and physical health, psychopathology,
executive function and aggression. Additionally, participants receiving the GIATS recorded less
substance use and criminal offending at T3 follow-up, providing evidence to support the
effectiveness of the intervention. These results are particularly encouraging, given the severe
deficits in cognitive functioning and level of comorbid presentations that were evident within both
Intervention and TAU groups at baseline, and continuing on some measures into follow-up.
Combining Cognitive Behavioural Therapy, Acceptance and Commitment
Therapy and Mindfulness
Understanding for whom, and under what conditions, treatments are most effective is essential for
developing personalised treatment approaches. Currently psychoeducation interventions developed
for use with substance-using populations are generally based on Cognitive Behavioural Therapy
(CBT) and designed for individual presentation. Although cognitive-based therapies have been
shown to be effective in working with some ATS users (Baker et al., 2004), many present with
chaotic behaviours in the first stage of treatment and may also exhibit substantial cognitive deficits.
Indeed, in this study results on measures of executive function showed cognitive deficits for some
participants in both groups akin to older persons with mild cognitive impairment. Therefore,
cognitive-based therapies may not be appropriate for all clients and there is a growing use of
Acceptance and Commitment Therapy (ACT) within the substance use field, with preliminary studies
of effectiveness showing promise (Batten & Hayes, 2005; Hayes et al., 2004; Smout et al., 2010).
© Lynne E. Magor-Blatch & James A. Pitts
Page 51
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Traditional CBT and ACT share a number of techniques and strategies, particularly with respect to
the use of behavioural interventions (Hofmann & Asmundson, 2008). Both include exposure
exercises, problem solving skills, role playing, modelling and homework. They both emphasise goal
setting and awareness of thoughts, feelings and sensations without attempting to control or hold
onto them. Both also target specific concerns and fears, and work towards improvements in overall
quality of life. However, there are important theoretical differences between each of the
interventions in relation to the role of cognitions.
ACT views cognitions as a form of behaviour, “a term for all forms of psychological activity, both
public and private, including cognition” (Hayes et al., 2006, p. 2), and therefore focuses on
identifying and altering the function of the cognition. Conversely, CBT focuses on both the content
and function, including maladaptive cognitions, with the goal to change the emotional response
associated with them. ACT promotes acceptance of undesirable emotions in the same way as
acceptance of any negative thoughts, whether these thoughts are adaptive or maladaptive, and asks
the person to assess and live by core values. Conversely, CBT asks that the person identify and
change negative thoughts.
Therefore, there is an important difference between CBT and ACT in their views of appropriate types
of emotional regulation strategies (Hofmann & Asmundson, 2008). More specifically, whereas
antecedent-focused strategies (such as CBT) attempt to regulate emotions prior to the processing of
emotional cues, response-focused strategies (ACT) attempt to do so after emotional responses have
already been activated and processed (Hoffman, Sawyer, & Fang, 2010). The blending of the two in
the GIATS was not perceived as problematic, with exercises and information from each being
endorsed and recalled at follow-up. Importantly, for participants with poor cognitive processing
ability and reduced emotional regulation, the ACT and Mindfulness interventions were more readily
accessible and understood. In follow-up, these were generally the activities and exercises which
were recalled.
Empirical data suggest that experiential avoidance plays a role in the development of substance
dependency and also acts as a deterrent to treatment (Wilson & Byrd, 2004). Experiential avoidance
is associated with anxiety disorders, depression, poorer work performance, higher levels of
substance use, lower quality of life and other risky behaviours (Harris et al., 2006). Therefore, the
use of substances is both stimulated by negative events and at the same time, used to regulate
them. This suggests that in terms of a treatment intervention, ACT may be a potentially effective
intervention. The underpinning philosophy of ACT is sympathetic to AOD treatment and it is well
suited to the treatment environment as it shares common ground with 12-step approaches (Wilson,
Hayes & Byrd, 2000), motivational interviewing (Budney, Higgins, Radonovich & Novy, 2000; Miller,
1996) and relapse prevention/harm reduction models (Carroll, 1996; Marlatt & Gordon, 1985).
The GIATS is specifically designed for group implementation, with activities that encourage group
interaction and sharing of thoughts and ideas to encourage group peer support. While much of the
material in the GIATS is well-known, the combination of CBT, ACT and Mindfulness, contained within
a Motivational Interviewing framework, makes the GIATS unique to other treatment protocols.
The GIATS also includes activities specifically targeted at acceptance and the development of valuesbased living. The assessment of personal values is particularly important for people entering
treatment, with the realisation of damaged personal and intimate relationships. The GIATS assessed
values on four domains: (1) relationships, which included family, intimacy, parenting and friendships;
(2) work, including workplace and career aspirations, education and training; (3) personal
growth/health, including physical and mental wellbeing as well as spirituality and religion; and (4)
leisure, including fun and activities.
Page 52
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
The GIATS therefore provides a worthwhile addition to the treatment literature, with few group
interventions thus far developed for use with substance-using populations. At the same time, it is
also proving useful with individual clients as a treatment intervention.
Importance to the AOD field
The results of the study provide wide support for this research and for its application to the AOD
field. The study identified significant areas of health concern for residents of TCs who have a history
of dependent ATS use that impacts on a range of outcomes, including substance use, mental and
physical health, and other psychosocial concerns, as well as criminal behaviour. The GIATS was
developed to address these issues and provide an addition to treatment as usual, with particular
application to the group setting. While results at T3 achieved statistical significance in one area only,
an improvement on one of the measures of executive functioning (Self-Monitor) for Intervention
group participants, a level of clinical improvement was also evident for Intervention group
participants at T3 which is encouraging, and supports the efficacy of the treatment intervention.
Participants involved in this study provided endorsement for the GIATS, particularly noting a number
of the ACT and Mindfulness interventions, and specifically activities targeted at acceptance and the
development of values-based living. A number also noted that the information had continued to be
of help since leaving the TC, stating that they had retained the worksheets and tip sheets as they had
been provided to them each week. Of particular note were the activities focusing on values, with
participants on follow-up acknowledging how their values had changed from entry to the TC to the
current time. For a number of participants, this had included regaining care of children following or
during treatment, and the development and ongoing improvement in family relationships was
therefore a goal that had been attained.
Comments from participants included:
· “I like that I felt more grounded after I participated in the program”.
· “Interaction and guidance”.
· “It let me have a good honest look at myself”.
· “Practical relevance”.
· “Included differing opinions on same task”.
· “Participation with others, discussion”.
· “Liked everything about the intervention. To think about consequentially and stop —
think before I speak. Thank you”.
· “Makes me aware of my own thought processes”.
· “It allows me to detach from my emotions in a situation enough to challenge my
thinking and make adjustments that serve me to move towards feeling peaceful. These
are powerful tools but it does take willingness on my behalf to continually use them in
situations”.
· “To remain abstinent, deal with negative thoughts, counteract irrational beliefs and
deal with core issue of not being good enough”.
· “By becoming more aware of thoughts, feelings, behaviours. Recognising fight or flight
responses and which emotions are attached to certain physical feelings”
· “Now understand how much my emotions and not voicing them contributed to my
addiction, so I'll be more open with this. Being more assertive and having boundaries
now will help too. I'll be accessing my support group in future, something I didn't do in
the past”.
Increasingly, AOD treatment services are under pressure from governments that are concerned with
the establishment and development of cost-effective treatment options which address the changes
in client presentations and drug availability, and from consumers who are looking for shorter-term
© Lynne E. Magor-Blatch & James A. Pitts
Page 53
Group Intervention for Amphetamine-Type Stimulants (GIATS)
treatment-effective options. Treatment services and TCs in particular, are progressively
incorporating more psychoeducation and individual counselling into the TC program. However, as
shown in this study, residents presenting with difficulties in cognitive and executive function may not
be suited to interventions that rely heavily on cognitive-based strategies. This study has provided an
option for consideration for treatment services. As the GIATS is further developed for other
treatment populations, it will continue to be evaluated and enhanced.
Page 54
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Module 1.
Aim: To build motivation for change.
Materials needed for Module 1:
•
•
•
Worksheet 4: Lifestyle issues causing problems in my life
Worksheet 5: Decisional balance – the pros and cons of continued ATS use
Writing materials – it is suggested that folders be developed for clients, in which they can
keep all materials, including the personal writing undertaken as part of this treatment
intervention, along with Tip Sheets, Worksheets, homework and other resource materials.
The folder should be brought to every session.
Key elements of Module 1.
Step 1 – Building motivation to change
These factors were nominated by ATS users in
New Zealand as key lifestyle issues in relation to
their continued ATS use.
• Argued with others
• Lost my temper
• Had reduced work/study performance
• Did something under the influence of
drugs that I later regretted
• Took sick leave/did not attend classes
• Couldn’t remember what happened the
night before
• Damaged some of my own property
• Had unprotected sex
• No money left for any luxuries
• Passed out
• Upset a family relationship
• I stole property
• No money for food or rent
• Damaged a friendship
• Got into debt/owing money
• Ended a personal relationship
• Got arrested
• Physically hurt someone else
• Got a traffic ticket
• Spent some nights sleeping rough (i.e.,
living on the streets)
• Sacked/lost business/quit study course
• Had a car crash
• Had sex and later regretted it
• Charged with a driving offence
• Was kicked out of where I was living
• Physically hurt myself
• Overdosed on drugs
• Was sexually harassed
• Was sexually assaulted
© Lynne E. Magor-Blatch & James A. Pitts
Distribute Worksheet 4: Lifestyle issues causing
problems in my life to help the client to articulate
some of the problems caused by their ATS and
other drug use.
Step 2 – Reviewing motivating factors
Invite the client to share one thing from the list
which is considered a major motivating factor for
change. If this is being undertaken in a group
setting, each person can be asked to pair with
one other person to share this. This should be
done with due consideration to the person’s
time within the program, their relationships with
others and the amount of trust they have
developed.
Ask for feedback to the larger group – ‘Does
anyone feel like sharing something about
yourself from that last exercise?’ Discuss.
Step 3 – The decisional balance
Distribute Worksheet 5: Decisional balance – the
pros and cons of continued ATS use and explain
this to the client or group.
• The decisional balance is used to help us
think through what are the good things
and the not so good things about
continuing to use – and in particular the
things that became associated with the
use of drugs.
• It also looks at the good and the not so
good, or the difficult things about
changing.
If this is undertaken in a group format, it can be
done on the whiteboard with everyone
contributing. Each person should then fill in the
sheet with information applicable to them.
Page 55
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Step 4 – Assessing the decisional balance
If this is being conducted on an individual basis,
go through the exercise with the client, asking
the person what were the good and not so good
things about using; and then what do they think
will be the good and less good things about
stopping. Ask what is the importance of each
factor. For instance, the client may have fewer
reasons for stopping than continuing, but the
weighting on each of these may be far higher
than the weighting on the reasons for
continuing.
Establish whether the positive reasons outweigh
the negative in terms of the number of issues
listed for and against change, as well as the
importance ratings attached to each of the
factors.
Step 5 – Strengthening commitment
There may be resistance during this phase.
Miller and Rollnick (1991) identified four
categories of resistance behaviour in clients:
1. Arguing about the accuracy, expertise or
even the integrity of the therapist or
clinician. Therefore the person may be
challenging, discounting or even hostile.
2. Interrupting in a defensive manner. This
may mean that the person talks over
others, or cuts them off when they are
speaking.
3. Blaming, disagreeing or denying any
problems. There is an unwillingness to
recognise problems or to take
responsibility.
4. Ignoring or not following the worker or
clinician.
In response to this, Miller, Zweben, DiClemente
and Rychtarik (1995: 24) suggest:
• Reflection – simply reflect what the client
is saying;
• Reflection with amplification – reflect,
but exaggerate what the client is saying to
the point where the client is likely to reject
it. (But beware, don’t overdo it, or the
person may become hostile).
• Double-sided reflection – reflect a
resistant statement back with the other
side (based on previous statements made
in the session).
Page 56
• Shift focus – shift attention away to another
issue.
• Roll with resistance – don’t oppose – gentle
paradoxical statements will often bring the
person back to a balanced perspective.
Step 6 – Explore concerns
“You’ve said there are less good things about
using speed or ICE – do these things concern
you?”
Explore health risks – “What do you think the
effects on your health might be with continued
use?” “Some people think giving up
methamphetamine, ICE, speed etc can improve
their depression. What do you think?”
Other factors important to the person may be
financial costs, losing contact with family –
especially a partner and children.
This can be undertaken in a group format –
either in a full group if there are 10 or less
members, or in pairs.
Step 7 – looking back, looking forward
“What was it like before you started using?”
“How different would you like things to be in the
future?” “What are your hopes for the future?”
Help to develop discrepancy –
“If I was to ask your mum, best friend, partner,
what were your best qualities, what would they
say?” “How would you describe the things you
like about yourself?”
Step 8 – if the person is ambivalent, explore the
reasons for this and re-establish the reasons for
coming into treatment. Incorporate the
information on health and psychological effects
of continued use. Take clients back to their
concerns on the Lifestyle questionnaire and
decisional balance.
Ask the person or group, “What happens as we
put distance between ourselves and the things
we saw as problems?”
The answer – they don’t seem so bad!
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Motivation for change has historically been regarded as a prerequisite for responsiveness and
readiness for treatment (Miller & Tonigan, 1996). Motivated clients are considered to be interested
in changing and able to identify realistic goals. They may have an understanding of the basis of their
symptoms and view therapy as an opportunity for self-exploration (Rosenbaum & Horowitz, 1983).
Conversely, lack of motivation for change has been seen as a result of defence mechanisms, such as
denial, which pose obstacles to treatment and rehabilitation.
An alternate view considers motivation to be a fluctuating state of balance between the pros and
cons of a behaviour where motivational states may be influenced by a variety of factors in the social
environment (Miller, Benefield, & Tonigan, 1993). Clients may be reluctant to change the antisocial
behaviours that define them. They may lack self-reflection skills and externalise problems by acting
out or abusing substances. They may also be suspicious and distrustful of those in authority who
attempt to help, especially where treatment is mandated (Eliany, 1992).
Research on TC populations has shown that, generally speaking, clients entering a TC have reached
the Action stage (Magor-Blatch & Rickwood, 1999). However, if we consider motivation as a
fluctuating stage, influenced by both internal and external factors, we are also able to understand
that a person may move from the Action Stage back to the Contemplation or even Precontemplation
Stage in response to both internal and external factors.
Initiation of substance use
Precontemplation
Cessation of substance use
Precontemplation
Contemplation
Contemplation
Preparation
Preparation
Action
Action
Maintenance
Maintenance
Relapse
Figure 1. Stages of change for initiation and cessation of (harmful) substance use
Step 9 - The Process of Recovery
The group or client has now identified some specific effects of their drug use on themselves, possibly
their families or significant others.
· Define recovery from drug use as a long-term process of stopping the use + change.
· Identify the various components of recovery: physical, emotional, family, social, and
spiritual.
· Define denial as one of the key psychological issues to deal with in recovery, and identify
ways to work through it.
Methods/Points for Group Discussion
Use discussion format to elicit and review the clients’ answers and record responses on the
whiteboard.
© Lynne E. Magor-Blatch & James A. Pitts
Page 57
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Ask the group or client – “When you think of Recovery what do you think the different aspects of
this might be? For example, we might think of Physical Recovery and Emotional Recovery. What
other areas of our lives are important in the recovery process?”
Write the following aspects on the whiteboard:
· Physical Recovery
· Emotional Recovery
· Social Recovery
· Family Recovery
· Spiritual Recovery
There may be others that clients may suggest. If so, put these up as well.
Recovery involves making changes in oneself (internal change) and one’s lifestyle (external change).
Improving or developing new coping skills is essential for change to occur.
·
·
·
·
·
Physical recovery involves good nutrition, exercise, getting adequate sleep, relaxation, and
taking care of medical or dental problems.
Emotional recovery involves learning to cope with feelings, problems, stress, and negative
thinking without relying on ATS or other drug use.
Social recovery involves developing relationships with sober people, learning to resist
pressures from others to use, and developing healthy social and leisure interests to occupy
time.
Family recovery involves examining the affects of drug dependency on one’s family,
involving the family in recovery, and making amends.
Spiritual recovery involves learning to rely on a higher power for help and strength,
developing a sense of purpose and meaning in life, and taking other steps to improve one’s
‘inner life’.
Step 10 - Define denial and ask clients to give examples of their own use of denial. State that a key
early recovery challenge is breaking through ‘denial’ of dependency and motivating oneself to work
on an ongoing program of change. Recovery is best viewed as a ‘we’ process in which the person
uses the support of others, especially other individuals who are now sober and no longer use alcohol
and other drugs.
Step 11 – The next step is to consolidate the
issues raised by the client, and to build on their
motivation for change. Shift the focus to
negotiating a plan for change. The final task will
be to help the client determine an initial goal.
This is a short term goal which they will be able
to achieve by the next session. Set just one.
Explore any fears through problem solving for
each fear raised. Talk through the characteristics
of goal setting - pointing out that goals can help
regardless of whether or not they are achieved.
Page 58
Goals need to be concrete, measurable, and
realistically achievable. Clients in the
Preparation and Action Stage may need practical
assistance with approaching goals in manageable
steps. These may be modelled through problemsolving strategies to assist clients with working
through practical issues with goal selection and
attainment.
Continued use of motivational interviewing
strategies, particularly supporting self-efficacy,
are important to maintain commitment.
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
There are a number of Tip Sheets which form part of the next module. These are:
• Tip Sheet 4: Some facts about Cravings
• Tip Sheet 5: Drug Treatment Metaphor
• Tip Sheet 6: Pavlov’s Dog
• Tip Sheet 7: The Bridge Concept
As a prelude to Module 2, Tip Sheet 5: Drug Treatment Metaphor, Tip Sheet 6: Pavlov’s Dog and Tip
Sheet 7: The Bridge Concept, could be used in a Concept or Education Group to set the scene and
reinforce the learning which will be gained in the next module. In particular, The Bridge Concept has
been used by many TCs over the years, and adapted to their own individual program. The
adaptation here can be applied to all programs, and as with all materials it is important that clients
apply the information to their own lives. This is the prime value of concepts and metaphors in the
treatment setting.
© Lynne E. Magor-Blatch & James A. Pitts
Page 59
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Page 60
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Module 2.
Aim: To learn how to understand and cope with cravings.
Materials needed for Module 2:
•
•
•
•
•
•
Tip Sheet 4: Some facts about Cravings
Tip Sheet 5: Drug Treatment Metaphor
Tip Sheet 6: Pavlov’s Dog
Tip Sheet 7: The Bridge Concept
Worksheet 6: Vitality vs. Suffering Worksheet
Worksheet 7: Vitality vs. Suffering Diary
Key elements of Module 2.
Step 1 – Review last session. Ask client(s) to
take out their goal from last session. Were they
able to achieve it? What were the things that
helped them achieve the goal – and what were
the barriers that made it difficult? How did they
overcome them?
Was there a point when they thought they would
not be able to achieve the goal? Ask the client(s)
to write down what the problem was, what their
thoughts were or ask each person to state the
issues or concerns and write them on the
whiteboard.
Step 2 – Understanding and coping with
cravings. This is frequently cited as one of the
most difficult problems for ATS, and especially
methamphetamine users, to deal with (Lee,
et.al., 2007). Cravings can last weeks and even
months, causing issues for clients in the early
stages of treatment. This is the point where
there is greatest attrition, so it is important that
clients gain an understanding of the reasons and
the triggers for cravings and learn to normalise
the experience and to develop skills to manage
the cravings when they occur.
Handout: Tip Sheet 4 – Some facts about cravings
Step 3 - Understanding cravings. Craving refers
to an impulsive, spontaneous urge to use ATS,
methamphetamine or other substances. A
craving may include strong thoughts of using
drugs, physical symptoms such as heart
palpitations and sweating, or behaviours such as
pacing. Cravings are triggered by many external
stimuli in the environment, such as the sight or
© Lynne E. Magor-Blatch & James A. Pitts
smell of substances or people, places, events,
or experiences related to substance use (e.g.,
drug dealer, friends who use, places where
using occurred, music associated with getting
stoned, etc.). Cravings also are triggered by
internal factors, such as obsessions or thoughts
about using drugs, or mood states such as
anxiety, boredom, or depression.
Cravings to use are temporary and will pass in
time. The client needs to use coping strategies
to resist giving in to a craving.
The first step in normalising cravings is
understanding the variety of situational, social
and psychological triggers which have been
associated with use (Lee, et.al., 2007). This is
essentially a Classical Conditioning model. Ask
about Pavlov’s dog? Does anyone know this
story? Give out Tip Sheet 6: Pavlov’s Dog.
Ask each person to give an example of a
situation in which they can identify this
phenomenon. It might be lunch being called, or
a group being announced. What are the
feelings and where do they experience them?
For example, fear may be felt in the stomach,
excitement in the chest. Do they get anxious,
what happens? Does their heart start racing,
palms get sweaty? These are normal reactions.
What have they done in the past when these
feelings have been experienced?
Encouraging clients to tolerate conditioned
cravings is also facilitated by stressing the timelimited nature of cravings. For most people,
cravings peak and dissipate within an hour.
Page 61
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Without further use, the mechanism of
extinction will lead to the weakening of the
conditioned craving response over time (Lee,
et.al., 2007).
Step 4 – It is possible to fit the person’s
experience of cravings into the following model:
Behaviours + Physical + Thoughts = Cravings.
It is important to use coping techniques that
address each of these elements in order to cope
with cravings (Baker, et.al., 2003).
Identifying triggers. Understanding triggers is a
very important part of this process. Triggers
refer to experiences, people, situations, events,
or things (objects) that stimulate a desire or
craving to use drugs or other substances. A
trigger can lead to a relapse if the person doesn’t
have coping strategies to manage the craving.
Therefore, part of changing drug using behaviour
is also about changing the places and the
friendships associated with drug use.
What have been some of the triggers to drug use
in the past? Brainstorm these on the
whiteboard. Begin to generate some ideas
about how these situations could be coped with
differently if you apply the ‘Pavlov’s Dog’ model
– i.e., that extinction would follow if the reward
didn’t arrive.
Clients may experience direct and indirect social
pressures during recovery. These pressures
can lead to relapse if the person is not prepared
to handle them and refuse offers of alcohol or
other drugs.
Part of this process, is assisting clients to
‘recognise, avoid and cope’ (Lee, et.al., 2007).
While there is safety in the TC and therefore
avoidance of some situations will be relatively
non-problematic, avoidance in itself is not
without risks. Simply avoiding all social contact
and activity is counter-productive.
A problem solving approach to working around
triggers and cues to drug use is helpful,
particularly if there can be some collaborative
‘reality testing’ of the workability of each
strategy.
For many clients who are entering treatment in
their ‘home town’ attending support meetings
(NA and AA for example) in locations where
using took place can be described as changing
the cues to using.
So instead of scoring, you go to a meeting, have
a coffee with ‘clean’ friends afterwards – and in
doing this you start to change the cues (‘this is
where I score’), to the trigger (the location) and
have a different outcome (meeting and coffee
instead of using).
Ask clients to give examples of social pressures and other triggers to use drugs or alcohol. After
eliciting clients’ examples of triggers, review the common triggers listed below and add any to the
list on the whiteboard that clients didn’t Identify:
Step 5 - Social Pressures and Triggers to Use Alcohol and other Drugs
· Drug-using friends or family members.
· Dealers.
· Events or celebrations where alcohol or drugs are present.
· Music associated with partying or using substances.
· Sex and sexual partners.
· Drug paraphernalia.
· Places where drugs were obtained.
· Places where drugs were used.
· Some jobs (particularly if people used drugs on the job).
· Money or the anticipation of getting money.
· Weekends or celebrations.
Page 62
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
·
·
·
·
Certain smells, even the smell of matches.
Feeling lonely, sad, angry, bored, or depressed.
Positive memories of using.
Negative thoughts of recovery.
Discuss how to avoid the triggers that members have identified as powerful.
Ask the group members to identify strategies that they’ve used in the past or could use in the future
to manage a drug craving or resist social pressures to use.
Step 6 - Behavioural Strategies
Discuss the ‘3Ds’ of coping:
1.
Delay the decision to use when a craving occurs: This means delaying the decision to act for
a period of time – 1 minute, 2 minutes, 3 minutes as the person gains more confidence and
mastery over their feelings. This will help break the habit of immediately reacting to a
craving, and can be applied to other areas of concern in the person’s life.
2.
Distract yourself from thoughts about using: Generate some ideas for strategies to use as a
distraction technique. These should be written down and kept accessible by each person to
use as a reference when things become difficult. This might include the following:
· Talk to a peer, a staff member or call a friend or sponsor to discuss the craving.
· Go to an AA, NA, or other support meeting.
· Get some physical exercise.
· Read, particularly about recovery.
· Spend time with sober people.
· Keep busy.
· Undertake an activity.
· Avoid high-risk people, places, and events.
3.
Decide not to use again by thinking through all the reasons for stopping in the first place:
Congratulate yourself for not giving in and remind yourself – it’s only a THOUGHT or a
FEELING (Baker, et.al., 2003).
Step 7 - Cognitive Strategies
· Remember that cravings and desires for substances eventually go away.
· Think positively and tell yourself you can fight off your craving.
· Talk yourself through the craving.
· Pray or ask for strength from your higher power.
· Practice ahead of time how to refuse substance offers.
Step 8 - Relaxation and imagery
Relaxation techniques and deep breathing are important techniques to learn and use in response to
stressful situations. Using a relaxation CD will assist in developing skills which the person can then
apply when they become stressed or anxious. Other skills, such as ‘urge surfing’ (refer to Tip Sheet
4) should be discussed and utilised to increase the person’s chance of successfully resisting cravings.
© Lynne E. Magor-Blatch & James A. Pitts
Page 63
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Acceptance and Commitment Therapy (ACT)
(The following is meant as information for facilitators in preparing the session).
Suffering is a basic fact of life for humans. However, suffering is not just about pain, psychological or
otherwise. It's much more than that. We don’t just experience pain; we agonise over painful
memories, uncomfortable emotions, difficult self-evaluations, often ruminating over and over, even
though the past cannot be changed. These memories and situations worry us, and we may engage
in all kinds of activities to avoid them. People want the suffering in their lives to be minimised. For
people who have pushed away these memories and feelings for a long time with the use of drugs,
suffering has become a way of life, which is not even recognised as suffering. A good life is much
more than simply a lack of suffering. We want to live well and make the best of our time on this
earth.
While Acceptance and Commitment Therapy (ACT) is about the problem of human suffering, it’s
about much more than that. It’s about reaching beyond suffering to the larger purpose of people's
lives and helping them get active in really living. ACT is centred on such questions as “What do you
really want your life to be about?” or “If you lived in a world where you could have your life be about
anything, what would it be?" (Harris, 2007).
ACT is a cognitive-behaviour therapy that has gained increasing attention in recent years. ACT
emphasises such processes as mindfulness, acceptance, and values in helping clients overcome
obstacles in their lives. A basic assumption of ACT is that suffering is a normal and unavoidable part
of human experience and that it is actually people's attempts to control or avoid their own painful
experiences that lead to much long-term suffering. ACT helps people learn ways to let go of the
struggle, be more mindful, get clarity on what really matters to them, and to commit to living full,
vibrant lives. The goal of therapy is not to eliminate certain parts of one's experience of life, but
rather to learn how to experience life more fully, without as much struggle, and with vitality and
commitment (Harris, 2007).
ACT uses exercises and metaphors to assist clients. Hand out the Tip Sheet 5: Drug Treatment
Metaphor. Ask client(s) if they can think of ways in which they use metaphors to help them cope
with or understand situations. These are often used in the TC as ‘concepts’.
Hand out Tip Sheet 7: The Bridge Concept from the Tip Sheets section. This concept has been used
by TCs for many years, and may have been adapted to individual programs. It gives a pictorial image
of moving from where you have been, to where you might want to be in the future.
Step 9 - Vitality vs. Suffering
The next exercise comes from Acceptance and Commitment Therapy (ACT) and was developed by Dr
Russ Harris (2007). Hand out Worksheet 6: Vitality vs. Suffering Worksheet.
Introduce this exercise by asking client(s) to think about the main thoughts and feelings that they
struggle with – the ones that get them down, interfere with their lives, or set them up for a struggle
with themselves or others.
There are two circles which represent mind and body. In the body circle, they should write down
whatever they struggle with that they can feel in their bodies, including the sensations, urges,
cravings, (and sometimes symptoms of physical illness). In the mind circle, they should write down
Page 64
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
whatever they struggle with in terms of thoughts, self-judgments, memories, worries, fantasies –
and any beliefs or ideas that seem to set them up for a struggle with their own lives, or with other
people. Some things, such as fear or anger, may be experienced in both body and your mind – so
they should be written in the area where the circles overlap (Harris, 2007).
As they are writing, it is helpful to do some subtle defusion, by asking questions like: “When your
mind seems to be really giving you a hard time, telling you what’s wrong with you or your life, what
are some of the nastiest things it says to you?” Or if the client writes down a stream of negative selfjudgments, you might say, “Your mind really likes to give you a hard time, doesn’t it? How long has it
been telling you this sort of stuff? What’s the earliest you can remember it trying to tell you what
was wrong with you?” (Harris, 2007).
Once that part is completed, let people know that what they have written are the kinds of things
they struggle with. It’s not a comprehensive list of every thought and feeling and memory that ever
troubles them – but it gives a general overview.
Now point out the top half of the sheet - ‘Vitality’. Vitality is what we’re aiming for in this work: a
sense of wellbeing, a sense of being fully alive. So on the top half, ask everyone to write down all
the positive things they have ever done when these difficult thoughts and feelings showed up – i.e.,
things that that improved their lives, health, happiness and vitality in the long term. Sometimes it
didn’t feel that way, it felt hard, but the long term benefit was positive.
Having completed that part, draw attention to the bottom half of the sheet – ‘Suffering’. Suffering is
what we’re aiming to reduce. Suffering means everything that they EVER do, when these painful
thoughts and feelings show up, that makes their life worse. These are all the negative things that
they’ve EVER done when these thoughts and feelings showed up – all the ways they wasted their
time, energy, and money, or damaged their health, or hurt their relationships and the people they
cared for, or otherwise worsened their lives in the long term (Harris, 2007). Once again, some
things, like using, might have felt good in the short term, but the long term effects are what they
are now dealing with.
This is a powerful exercise, as we don’t often think about these issues in such strong terms – Vitality,
Suffering.
Step 10 – Homework. Worksheet 7: Vitality vs. Suffering Diary.
This is to be done over the next week. Introduce it by saying you would like everyone to maintain a
diary, to keep track of what’s happening in their lives and to help them to begin to understand the
way in which they react to situations – especially as many of these will have become automatic
coping mechanisms.
The idea is to become aware throughout each day, of the difficult thoughts and feelings as they show
up. Ask everyone to write down the thoughts and feelings in the first column. Then write down
what they do in the other two columns.
If what they do seems to improve their lives in the long term, if it makes them begin to feel that life
is rich and full and worth living, and improves their health, vitality, and relationships, then write it in
the vitality column.
However, if what they do seems to worsen their lives in the long term, these things should be
written in the suffering column.
© Lynne E. Magor-Blatch & James A. Pitts
Page 65
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Again, emphasise the words ‘LONG TERM’ here, because that’s what we’re interested in: the big
picture. If they do something that makes them feel good in the short term, but negatively impacts on
health, wellbeing, vitality, or relationships in the long term – then that should go into the suffering
column.
This will take five to ten minutes each day to fill in and should be done at a specified time. Ask each
person to specify when they will elect to fill it in, e.g., immediately after lunch, or before they go to
bed.
Ask each person to do the first entry so that they understand how it works. Discuss this.
As there are no Tip Sheets included in next module, it may be possible to check in with clients in the
time before the next session to see how they are going with the homework. Doing homework is not
necessarily part of the person’s thinking – so this may be somewhat difficult in the beginning.
However, this is one activity which was found by participants in the trial to be very useful, therefore,
if they are able to complete it, the Vitality vs. Suffering Diary will be helpful in understanding how we
act and what the end result of those actions might be for each person.
Page 66
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Module 3.
Aim: To understand how thoughts influence behaviour.
Materials needed for Module 3:
•
•
•
Worksheet 8: Unhelpful thinking patterns
Worksheet 9: Self-monitoring record
Packet of raisins, with enough for the group, placed on a plate. The Raisin Exercise,
however, is optional and might be replaced by another meditation or relaxation exercise.
Therefore, both are provided here, but only one should be used with the group.
Key elements of Module 3.
Step 1 – Last week’s homework – The Vitality vs. Suffering Diary. What did each person gain
from this? What did they notice, were there more Vitality or Suffering reactions?
Point out that it is normal to be reacting in a way that increases suffering at the beginning, but that
as they become more aware of their thoughts, feelings and emotions, they will also start to
consider the way in which they react and the consequences of this.
Step 2 – Reframing reactions. Ask each person to give an example of one way in which they
reacted that increased their Suffering, rather than Vitality. List these on the whiteboard.
Now ask the group for suggestions about the way in which these might be reframed – i.e., instead
of acting in a way to increase suffering, what might the person have done to increase their vitality?
Step 3 – The Raisin
Exercise (This exercise is optional and could be replaced with the
Floating Leaves on a Moving Stream Exercise, provided below).
This is a Mindfulness exercise that helps to do a few important things. Firstly, it slows us down,
so it is often used as a stress reduction exercise, secondly, it helps us to become aware of our
senses, and this is very important for people who have become cut off and are no longer in touch
with feelings. Finally, we ask people to do this mindfully, i.e., to consider each step in this
process, to be aware of what they are doing.
Offer each person a raisin from a plate which you will pass around. Ask each one to pick up a
raisin. Look at it. Really look at it - like you've never seen a raisin before. Roll it between your
fingers. What do you notice about its texture, its colour? If you were to put the raisin back onto
the plate, would you be able to recognise it again? What are the particular things about this
raisin that you notice? Give a few moments for this and each stage.
Then ask each person to hold the raisin to their ear. You shouldn’t put it in your ear, you will be
eating it later – so just hold it there. Squish it a bit. Does it make a sound?
Now take it to your nose. How does it smell? Ask each person to close their eyes at this point, so
they can really concentrate focus their awareness.
Now ask each person to bring it to their lips. Ask them to take note of any stray thoughts they
might have, but always come back to the raisin. Place it on your tongue. Just hold it there. What
are you aware of now that you have it in your mouth?
© Lynne E. Magor-Blatch & James A. Pitts
Page 67
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Then ask them to bite into it. Savour it. When you finally swallow it, appreciate the fullness of its
flavour. Now ask each person to imagine that their bodies are exactly one raisin heavier.
At the end of this exercise, ask for feedback. Some people will feel it’s a bit silly, but what was it
like when they were attending, being aware and mindful about the task and about the raisin?
Step 3 (Alternate exercise) – Floating Leaves on a Moving Stream
Do this exercise for at least five minutes. Keep a watch or a clock and note when you start the
exercise. This will be useful in answering some of the questions at the end of the exercise.
This will be an eyes-closed exercise.
Imagine a beautiful slow-moving stream. The water flows over rocks, around trees, descends downhill, and travels through a valley. Once in a while, a big leaf drops into the stream and floats away
down the river. Imagine you are sitting beside that stream on a warm sunny day, watching the
leaves float by. Now become conscious of your thoughts. Each time a thought pops into your head,
imagine that it is written on one of those leaves. If you think in words, put them on the leaf as
words. If you think in images, put them on the leaf as an image. The goal is to stay beside the
stream and allow the leaves on the stream to keep floating by.
Don't try to make the stream go faster or slower; don't try to change what shows up on the leaves in
any way. If the leaves disappear, or if you mentally go somewhere else, or if you find that you are in
the stream or on a leaf, just stop and notice that this happened. File that knowledge away and once
again return to the stream, watch a thought come into your mind, write it on a leaf, and let the leaf
float away down the stream.
Hayes, S. C. (2005). Get Out of Your Mind & Into Your Life. P. 77. New Harbinger Publications, Oakland CA.
At the end of the exercise, ask the following questions:
· How long did you go until you got caught by one of your thoughts?
· If you got the stream flowing and then it stopped, or if you went somewhere else in
your mind, what happened just before that occurred?
· If you never got the mental image of the stream started, what you were thinking while
it wasn't starting?
Step 4 - Link between thoughts and behaviour:
the ABC model. It helps to explain the CBT
model. Explain the CBT model by starting with
the simple concept that the way in which we
interpret situations determines how we feel and
behave (Lee, et.al., 2007). Role play this with an
older resident or another staff member.
Write A, B, C on the whiteboard. Explain the A
stands for Activating Event. This might be an
actual event, or it might be a thought or a
feeling that comes over the person.
Page 68
The B stands for Belief. These are the things we
think and believe about ourselves and others in
response to the situation.
C stands for Consequences and these are
usually the actions we take as a result of both A
and B. It might be a behaviour or it might be
the way that we feel as a result of what has
happened.
Mapping this out on the whiteboard, ask the
person to give you an example of a situation to
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
which they reacted recently. This might be
something like, “When I got up this morning
and came down to breakfast, one of my peers
ignored me when I said hello”. (This goes in A).
Ask the person what they were thinking when
that happened. The person might respond, “I
thought, well stuff you! Do you think you are
better than me? It made me think I wasn’t good
enough to talk to, like I was a piece of crap!”
Put this in B. Point out this is also beginning to
paint a picture of what the person believes
about him/herself.
Next ask what happened then? The person
might say, “Well instead of sitting next to the
person for breakfast I went and sat with
someone else, even though I knew the person I
sat with has got one foot out the door”.
Ask some more questions – what happened
next, and how do they feel now?
The response might be, “I felt even worse, the
person I sat next to was in a full-on negative
rave. It just brought up a whole lot of things. I
got really angry and stormed out of the dining
room. I still feel really upset, it’s brought up a
whole lot of things about how I never seem to fit
in.”
Step 5 - Unhelpful thinking patterns. Ask the
group what they were thinking as they listened
to this scenario – could the person have got it
wrong at the beginning, i.e., could there have
been another reason why the first person didn’t
answer? What if the first person didn’t hear the
greeting, what if he or she was in their own
space and it had nothing to do with the person
who has now become affected by this?
On the whiteboard, ask the group to generate
as many different explanations for this event as
they can think of. Record all of these.
Many clients will have difficulty generating
alternative ways to interpret the situation. You
may need to prompt or brainstorm alternatives
(Lee, et.al., 2007).
Step 6 – Naming unhelpful thinking patterns.
Distribute Worksheet 9: Unhelpful thinking
patterns. Ask the group what were the
unhelpful thinking patterns demonstrated by
the last exercise. Write these on the
whiteboard.
Ask each person to pick out their 2 ‘favourite’
unhelpful thinking patterns from the Worksheet
and see if they can give an example. This can
also be done in pairs or small groups. What
have been the consequences of these thinking
styles?
This goes in C, but you can also add the bit
about never fitting in, into the B column.
Step 7 - Self monitoring. Once a person has identified the unhelpful thought patterns that apply to
them, it is important to learn ways to identify and challenge them. The main steps to changing
unhelpful thought patterns is first to recognise it when it happens, to ‘catch yourself thinking in this
way, recognise the thought pattern for what it is, and then substitute it with a more helpful or
reasonable set of thoughts’ (Lee, et.al., 2007: 53).
Breaking events down into situations, unhelpful thoughts, feelings and behaviours can take practice.
It is important to ask each person to practice this skill in between sessions. By asking the client to
‘self-monitor’, they will begin to gain new awareness about their thoughts and feelings and how they
lead to behaviours, including alcohol and other drug use (Lee, et.al., 2007).
Step 8 – Distribute Worksheet 9: Self-monitoring record. This diary includes the A, B, C model which
was practised at the beginning of the session, and also includes a column to write down the
unhelpful thinking styles that may been used. Finally it introduces ‘D’ – Detective Work and
Disputation. So if the person has recorded something in the previous column that points to a
© Lynne E. Magor-Blatch & James A. Pitts
Page 69
Group Intervention for Amphetamine-Type Stimulants (GIATS)
particular type of thinking pattern, they have to ask, where’s the evidence that this is the case? This
is the first ‘D’ – Detective Work.
· It is common for people to mistake their feelings for evidence/fact – when in reality feelings
are not facts. Often the evidence is contradictory to the person’s thoughts and feelings.
· What are the advantages/disadvantages for thinking this way? The idea that someone can
get a positive benefit from a negative thought might be challenging. Explore this. Sometimes
it allows people to stay exactly where they are. They don’t need to change and they can go
on behaving the way they have been. What would happen if they challenged some of these
thinking patterns?
· Is there a thinking error? Is the person falling into one of the unhelpful thinking styles? Ask
clients to review the list and consider if they are falling into one of these patterns.
The second part of ‘D’ is Disputation · What are the alternative ways of thinking about this situation? There will always be more
than one way to interpret a trigger situation. Often these alternatives will be more helpful
than the previous interpretations and consequences which result from unhelpful thinking
styles.
Brainstorm some alternative ways of thinking/reacting to stressful/trigger situations with the group.
Filling out this worksheet is the homework task for this week.
Page 70
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Module 4
Aim: To understand feelings and make the Mind/Body connection.
Materials needed for Module 4:
·
·
·
·
·
Tip Sheet 8: Managing your Feelings in Recovery
Worksheet 10: Understanding how we experience Feelings
Worksheet 11: Feelings of Anger, Loss, Shame and Guilt
Worksheet 12: Pleasant Events Calendar
Coloured pencils or crayons
Key elements of Module 4.
Step 1 – Relaxation Exercise
This relaxation exercise can be used to calm or soothe. Read the following script:
“Let’s start by finding a position where you are comfortable. You can sit in your chair, or if you feel
comfortable, find a place on the floor where you can lie down without bumping into anyone.
Close your eyes, or if this doesn’t feel comfortable, leave them open and allow yourself to hold a soft
focus on an object or the ground just a little way in front of you. Take a deep breath while you
silently count to four: one...two...three...four. Now breathe out slowly, one...two...three...four. Try
to breathe from your tummy, not just your chest. Breathe in again. And out again. Now, repeat
that slow breathing two more times.
Now, in your mind, I want you to picture your favourite safe place. Maybe you are in a park, by the
beach, in a favourite chair. Maybe you are lying in the sun. Picture that place in your mind and
imagine yourself there. Keep breathing deeply and very slowly. Starting with your head and
working down your body like a scan, let your muscles relax. Let your forehead relax. Let your
cheekbones relax. Let your jaw relax. Let your neck and upper shoulders relax. As you exhale,
imagine all the tension going out with each breath. Let it go. Let your hands and arms go limp next
to you. Let your chest, stomach, and whole middle part of your body relax. Keep breathing in and
out. Let your hips, your buttocks, and your upper legs and lower legs relax. Let your feet and toes
relax. Let your whole body relax. Breathe in and out. Keep imagining that safe place you selected.
Enjoy where you are; enjoy the tension going out of your body. Be relaxed, almost floating and
weightless, as you stay with that image.
Now open your eyes. How do you feel right now? Do you feel more relaxed?”
© Lynne E. Magor-Blatch & James A. Pitts
Page 71
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Step 2 – Review the homework task – The ABC
Model. What were the key learnings from this
task? What were the unhelpful thinking styles
that each person found themselves slipping into?
How were they able to change these patterns?
and contain feelings is important so that feelings
are no longer able to control us.
Step 3 – Making the Mind/Body Connection.
Many things can impact on our emotional
development. Using substances will severely
impact on emotional wellbeing and
development, as will trauma. Often substance
use is the way in which we cope with traumatic
events. This may lead to ‘psychic numbing’ as we
shut down emotionally to help cope with pain.
Five steps to Emotional Wellness:
1. Become aware of when and how you are
feeling. Tune in to yourself.
2. Try to locate the feeling in your body.
Where are you experiencing the
sensations?
3. Name the feeling – label it.
4. Express the feeling.
5. Learn to contain it.
This may mean that we have become
unaccustomed to having feelings. If this has
happened, it may be necessary to find the words
to name these feelings. Learning to both express
The following five steps can help you begin to
create emotional wellness in your life.
Distribute Tip Sheet 8: Managing your Feelings in
Recovery. Discuss this.
Step 4 – Distribute Worksheet 10: Understanding how we experience Feelings and coloured pencils or
crayons. This worksheet provides a list of feelings, some of which will be familiar to members of the
group. Ask each person to choose one of the feelings from the list and to mark on the diagram
where in their body they experienced the feeling. They should choose an appropriate coloured
pencil or crayon to describe the feeling.
Use small groups, partners or the larger group to discuss this. What are the feelings that each person
chose? Where are they felt in the body? What colour did each person choose to describe the
feeling?
Choose another feeling – this time choose one which is different to the first, and one you would like
to feel more often. For example, if you chose ANGRY, then maybe you would like to feel HAPPY.
Where would this new feeling be experienced and what colour would it be?
Step 5 – Common feelings experienced by people who have used drugs include: ANGER, LOSS and
SHAME.
Sometimes when people feel ANGER, they turn it back on themselves, especially if they are unable to
express it. This may result in feelings of depression. Some anger may become self-harming
behaviour, and in some cases the anger will cover other feelings like FEAR. Fear or sadness can
sometimes be underneath anger.
Using the whiteboard, ask the group to brainstorm the ways in which they have shown anger in the
past. Then, making a second list, brainstorm some more healthy ways of expressing anger. How do
they use the processes in the TC or in recovery to more effectively deal with feelings of anger?
LOSS and GRIEF are common experiences for people who have abused drugs. Some people have
multiple losses, children, partners, family members and/or friends. Even the loss of their childhood
or youth and health will cause grief.
Page 72
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Ask clients to think back over their lives. Using Worksheet 11: Feelings of Anger, Loss, Shame and
Guilt, ask clients to think back over the losses they have experienced in their lives. They don’t need
to talk about these, instead they should record on the worksheet the ways in which these losses
have affected them. Did they use drugs to help cope with the losses? Where did this ultimately
lead?
Step 6 - Shame is a painful belief in one’s basic defectiveness as a human being. Shame can involve
feelings of humiliation, mortification, dishonour, or disgrace. Guilt refers to feeling bad about one’s
behaviours, including things one did or failed to do.
Examples of behaviours someone may feel guilty about include:
· Saying or doing things to hurt family or friends.
· Acting in a way that does not match your values.
· Committing crimes.
· Lying to and cheating others.
· Conning family members or using family money to buy drugs.
· Not acting responsibly as a parent or partner.
· Failing to take care of personal responsibilities.
Substance use invariably produces feelings of guilt and shame that damage the person’s self-esteem.
People who have used drugs usually experience feelings of guilt and shame over their behaviour
while they were using, and they may feel ashamed for using, or for the things they did while using.
This seems to be particularly true for ATS users. Some people may not feel worthy or deserving of
recovery.
Feelings of guilt and shame can give the person permission to continue to use drugs, and may result
in people dwelling on negative feelings about themselves, or denying or escaping from these feelings
by using.
People lose energy when they give themselves guilt and shame-producing messages and may use
drugs to give themselves a false sense of euphoria to change their mood.
Discuss strategies for healing guilt and shame such as:
· Recognise your guilt and shame.
· Give yourself time to feel better about yourself.
· Accept your limitations.
· Talk about your feelings of guilt and shame.
· Use a 12-step program.
· Make amends (steps 8 and 9).
· Seek forgiveness.
Step 7 – Finish up by filling in the sections on Shame and Guilt on Worksheet 11: Feelings of Anger,
Loss, Shame and Guilt.
Step 8 – Distribute Worksheet 12: Pleasant Events Calendar and go through this with the group. This
is the homework task for this week. Ask the group to commence the next day and to record one
pleasant event each day for the following six days before meeting again.
© Lynne E. Magor-Blatch & James A. Pitts
Page 73
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Tip Sheet 9: Fight or flight response, is one of the Tip Sheets in the next session (Module 5). This
might be used in the time between sessions in a Concept or other Educational Group to help clients
prepare for the next session, which teaches strategies to deal with anxious thoughts and feelings.
Understanding what causes stress, both real and imagined fears and threats, helps us to understand
how we can control these feelings and not allow them to rule our lives or to act in ways that are
counter-productive. Put another way, to understand how we can increase our Vitality, rather than
our Suffering.
Page 74
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Module 5.
Aim: To learn how to deal with anxious thoughts and feelings.
Materials needed for Module 5:
•
•
•
•
•
•
•
Tip Sheet 9: Fight or Flight Response
Tip Sheet 10: Coping with Anxiety: Bodily Symptoms
Tip Sheet 11: (Changing) The Anxiety Cycle
Worksheet 8: Unhelpful thinking patterns
Worksheet 9: Self-monitoring record
Worksheet 13: Anxious Automatic Thoughts Questionnaire
Worksheet 14: Coping Statements for Anxiety
Key elements of Module 5.
The value of relaxation and meditation has been highlighted in previous sessions. The 3-Minute
Breathing Space is a brief mindfulness meditation that will assist clients to expand their awareness
and to reconnect with the present moment – the here and now. This should be used at the
commencement or the end of each of the remaining sessions.
Step 1 - The 3-Minute Breathing Space - Basic Instructions
1. AWARENESS
Come into the present moment by deliberately adopting an upright and dignified posture. If
possible, close your eyes. Then notice:
“What is my experience right now… in bodily sensation…in feelings...in thoughts?”
Acknowledge and register your experience, even if it is unwanted. Allow yourself to be present, to
meet yourself, gently and with acceptance.
2. GATHERING
Then, gently bring your full attention to breathing, to each breath in and to each breath out, as they
follow, one after the other. If sound is a better anchor for you, then gently bring your awareness to
the sound around you.
Use your breath (or sound) as an anchor to bring you into the present and help you tune into a state
of awareness and stillness.
3. EXPANDING
Gently expand the field of your awareness around your breathing, so that it includes a sense of the
body as a whole… your posture … and facial expression.
Now gently bring your attention back into the room, and when you are ready, open your eyes.
Move your head from side to side, lift your shoulders, and let them drop. Stretch as you stand up,
and when you have stretched, sit back down again. How do you feel?
The breathing space provides a way to step out of automatic pilot mode and reconnect with the
present moment. The key skill using Mindfulness Based Cognitive Therapy (MBCT) is to maintain
awareness in the moment. Nothing else.
© Lynne E. Magor-Blatch & James A. Pitts
Page 75
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Step 2 – Review homework from last week, Worksheet 12: The Pleasant Events Calendar. What did
everyone find when they became aware of pleasant events? Was it difficult? Ask volunteers to
provide feedback.
Step 3 - Understanding cravings as anxious thoughts provides another way of looking at and
understanding some of our thinking patterns. These thoughts may then make us even more
anxious. When we are anxious we often imagine unpleasant and even frightening things are going
to happen. We may then look ahead and try to foresee and avoid problems. In anxious thinking, the
balance between expecting the worst and expecting good things is disturbed (Taylor, 2009). This
often leads to worrying about things before they happen – expecting the worst. When we expect
the worst, we often tell ourselves that we won’t be able to cope.
Here are some examples – and different ways of seeing the same situation. Brainstorm with the
group and write the responses on the whiteboard:
A disagreement with a peer...
Person A
She doesn’t agree with me
She thinks what I said was stupid
I am an idiot, I shouldn’t have said anything
I can’t handle this
I’m getting out of here
Result = Anxiety/Panic
Person B
OK, so we have a different point of view. That’s OK
It was an interesting discussion – we see things
differently
I don’t really agree, but it’s interesting
If we disagree, we can sort it out, talk about it
Result = Interested/Stimulated
Step 4 – Recognising anxious thought patterns will be similar to recognising unhelpful thinking
styles – and there are many overlaps. Distribute Worksheet 8: Unhelpful thinking patterns.
Becoming anxious is the feeling that often results from the thought. Ask the group, which of the
following examples of anxious thinking patterns apply to them:
· Thinking the worst – e.g., “I’ve got a pain in my chest, there’s probably something wrong
with my heart”.
· Predicting that the worst will happen – e.g., “They won’t like me, they’ll think I’m stupid”.
· Exaggerating negatives – e.g., “I made a complete mess of it, it was an absolute disaster”.
· Overgeneralising – If something happens once, you think it will happen again. e.g., Feeling
anxious when you go into town. “I always get anxious when I go out”.
· All or nothing thinking - e.g., “Unless I can do this without any mistakes, I’m a complete
failure”.
· Imagining you know what others are thinking - e.g., “I can tell that he is thinking that I’m a
complete idiot”.
Step 5 – Worksheet 13: Anxious Automatic Thoughts Questionnaire. This is an optional activity, and
you may therefore decide not to do this in the session. Instead, it might be used individually with
particular clients outside the session to assist them to understand more about their anxious
thoughts, and the value they place on these thoughts – i.e., do the degree of belief in the thought.
If you decide to use the questionnaire in the group, distribute to participants and ask each person to
complete them. You may find it is easier to do the first column (Frequency) first and then come back
to the second column (Degree of belief). Read out the instructions and demonstrate this by doing
the first 2 questions together so that everyone understands the task. Alternatively, the whole
questionnaire might be used as a group exercise.
Page 76
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
The questionnaire is scored by adding up the numbers circled. The higher the score, the greater the
anxiety and the degree of belief in the thoughts. The total score is not as important in this exercise
as understanding the source of the person’s anxiety and their belief in that thought. Hence, if
someone often has a particular thought, but doesn’t hold a strong belief in it, they are able to let it
pass through and not become anxious. However, if there is a strong degree of belief in the thought,
then this should be explored.
Step 6 – Ask each person to provide feedback on just one item. What did they find out, and how
does it tie back to the earlier discussion about anxious thought patterns? Can they associate it with
one of the patterns discussed before? For example:
·
·
·
Item 2: If I get criticised it means that I am wrong – Exaggerating negatives.
Item 11: I can tell that people will evaluate me negatively - Imagining you know what others
are thinking.
Item 14: Being anxious is a sign of weakness - All or nothing thinking.
Step 7 - Coping with anxiety begins with an understanding of the body's stress response. The body
undergoes three stages of stress. These stages are as follows:
1. Fight or Flight: During this stage, the body perceives threatened danger. A surge of energy
overtakes the body, enabling the person to fight off the threat or flee from the danger at
hand.
2. Resistance: This stage occurs when danger remains beyond the fight or flight period. The
body secretes several hormones in order to mobilise the body during long-term stress.
3. Exhaustion: If the body successfully completes the first two stages, it will enter a third stage,
exhaustion. This is a time when the fatigued body replenishes itself.
The Fight or Flight Response is the body’s response to perceived threat or danger. During this
reaction, certain hormones like adrenalin and cortisol are released, speeding the heart rate, slowing
digestion, shunting blood flow to major muscle groups, and changing various other autonomic
nervous functions, giving the body a burst of energy and strength. Originally named for its ability to
enable us to physically fight or run away when faced with danger, it’s now activated in situations
where neither response is appropriate, like in traffic or during a stressful interaction. When the
perceived threat is gone, systems are designed to return to normal function via the relaxation
response, but in our times of chronic stress, this often doesn’t happen enough, causing damage to
the body.
Distribute Tip Sheet 9: Fight or Flight Response.
Step 8 - Coping With Anxiety - When Does Stress Become a Problem?
Coping with anxiety is a necessity in our modern fast-paced world. Busy lifestyles, intensified by
many daily problems like traffic jams, money problems, work problems and relationship difficulties
keep many people in chronic states of stress.
Stress becomes a problem when a person undergoes a sense of prolonged danger. During the fight
or flight and resistance stages, the body produces many helpful hormones. However, excessive
amounts of these same substances can cause damaging effects to the body. For instance, adrenaline
helps with energy production during stressful periods. However, prolonged use of adrenaline by the
body leads to a weakening of the heart. Cortisol, which is released during the resistance stage,
© Lynne E. Magor-Blatch & James A. Pitts
Page 77
Group Intervention for Amphetamine-Type Stimulants (GIATS)
raises blood pressure and blood sugar levels and may narrow artery walls by increasing blood
platelets.
During prolonged stress, the body rarely has time to replenish itself. The body remains in a cycle of
fighting, fleeing, and resisting, with little or no time to rest. This affects the body's sleep cycle, only
increasing the body's fatigue and decreasing full restoration.
Coping with anxiety begins with understanding the symptoms of excess stress. These symptoms
include: exhaustion, sleep problems, tension headaches, constant worry, dark circles under the eyes,
bowel disturbances, lowered immune function, irritability or angry outbursts, lack of concentration,
and so on. (These are described in Tip Sheet 10: Coping with Anxiety: Bodily Symptoms).
Step 9 – Distribute Tip Sheet 11: (Changing) The Anxiety Cycle and Worksheet 14: Coping Statements
for Anxiety.
Tip Sheet 11: (Changing) The Anxiety Cycle describes the way in which we respond to long-held
beliefs about our response to anxiety-provoking situations. Changing this cycle can be accomplished
by putting in place coping mechanisms. Discuss each of these. What other mechanisms or
strategies can people think of?
Refer to Worksheet 14: Coping Statements for Anxiety. Where in the Anxiety Cycle could some of
these be used?
Step 10 – For homework during this week, ask clients to again fill out Worksheet 9: Self-monitoring
record. Provide a new copy.
There are no Tip Sheets included in the next module, but it may be useful to check with participants
during the intervening days or week to see how they are going with the homework task.
Page 78
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Module 6.
Aim: To understand and acknowledge core beliefs and values.
Materials needed for Module 6:
·
·
·
·
·
Personal Values Card Sort
Worksheet 15: Ranking of Personal Values Card Sort
Worksheet 16: Personal Values Exercise
Worksheet 17: Values ‘Bull’s Eye’
Worksheet 18: Cultivating Positive Affirmations and Vision
Key elements of Module 6.
Step 1 – Review last week’s homework: Self-monitoring record. Did anyone notice any changes
between this week and the last time this exercise was done? What were they? Discuss.
Step 2 – Values: What is important in my life?
It is possible that members of the group, your client or clients have never really stopped to consider
what is important in their lives – their core beliefs and values, and (looking at that word ‘value’ from
another perspective) what it is they value in life. Often we are unaware of our values because we
have never thought much about them. But as people come into treatment, this becomes a time for
re-evaluation, especially if people are beginning to feel, or have felt, unfulfilled in their lives. If this is
the case, it is often a sign that what we are doing does not match up with our core values.
This module will use some exercises to help each person assess what really matters to them.
Identifying personal values will make it much easier for each person to work out how they need to
adjust what they are doing in their lives in order to live by their values, or, from another perspective,
the things which they value.
Step 3 - Who inspires you? Ask each person to consider the following questions and to write down
their responses. These will be discussed in pairs or small groups.
If you could meet up with any famous character from history, a favourite character
from literature, or from a movie, who would it be?
What is it about this person that inspires you?
What would you like to ask them?
What characteristics of theirs would you like to adopt for yourself?
What does this tell you about yourself?
Ask for feedback to the larger group. Make a list on the whiteboard of the characteristics which
were highlighted by members of the group. Did any of these seem surprising? What is the
characteristic that most people value in others?
Step 4 – Personal Values Card Sort
This has been adapted from the one developed by Miller, C’de Baca, Matthews and Wilbourne
(2001) and is an activity that can be helpful when thinking about making changes. It is a way to
identify things that are really important to us, and learn a bit about ourselves.
The personal values cards are provided with the worksheets in this manual. Before starting, these
will need to be photocopied off and cut these into a set of cards for each participant.
© Lynne E. Magor-Blatch & James A. Pitts
Page 79
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Give each participant a set of cards with the three anchor cards (‘Not Important to Me’; ‘Important
to Me’; and ‘Very Important to me’) on the top of the pack.
1. Ask each person to place the three anchor cards in order in front of them (‘Not Important to
Me’ on the left; ‘Important to Me’ in the middle and ‘Very Important to me’ on the right).
2. Ask them to shuffle the 83 value cards; keeping the 3 blank cards separate.
3. Instruct the participants to sort the cards using the following script:
· “You placed the three title cards in front of yourself — ‘Not Important to Me’, ‘Important
to Me’ and ‘Very Important to me’. In your hands you have a stack of 83 cards. Each
card describes something that may represent a personal value for you. I would like you
to look at each card and place each card under one of the three title cards.
·
There are also three blank cards. If there is a value which is not on the printed cards, and
which you would like to include, write it on the card and put it in whichever pile you
would like. I would like you to sort all 83 cards, but whether you use the three additional
cards is optional. The only rule is that you can have no more than 15 cards under the
Very Important stack. After you have finished this part, I will ask you to do one other
small task. Do you have any questions?”
4. When participants indicate they are finished with the sorting, ask them to check the ‘Very
Important’ deck to make sure there are no more than 15 cards under this deck.
5. Read the following:
· “For the second task, I’d like you to focus on the top values you chose and sort them
from 1 to n (total number participant has in the most important pile—no more than 15)
using the ranking sheet. In this spot (point to #1) you will put the card that is your top
value. Then you will put your second top value here (point to #2). Then I want you to
write what this value means to you, like the example. Do you have any questions?”
6. Distribute Worksheet 15: Ranking of Personal Values Card Sort. When participants indicate
they are finished rank ordering the most important pile, check to make sure that the number
1 value is at the top, and they are in order from the most important down to the bottom of
the list and that they understand why the value is important to them.
Ask the group if anyone had any surprises doing that exercise. When they look at the way in which
they ranked their values cards, do they think this has changed over the past years? What about
since they first came into the program? What are the values which are now at the top of their list?
Step 5 - Distribute Worksheet 16: Personal Values Exercise. This task will follow on from the
previous one, and now that each person has been able to think their values through a little clearer,
they will have a better idea of where they sit in relation to each of these.
The worksheet has two parts – go over the first page with the client(s) so that each part is
understood. Discuss this, when everyone feels comfortable with the task, ask the group to fill out
page 2 with their responses. Explain they do not have to share their responses, but you will ask the
Page 80
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
group to feedback their general response. What did they find out about their values in each of the
categories? How did this tie into the first task?
Step 6 – Distribute Worksheet 17: Values ‘Bull’s Eye’. This exercise will take the values exercise a
step further, by asking each person to think about each area:
1.
2.
3.
4.
Relationships: includes partner, children, parents, relatives, friends, and other social
contacts.
Work/Education: includes workplace, career, education, skills development, etc.
Personal Growth/Health: may include religion, spirituality, creativity, life skills, exercise,
nutrition, and/or addressing health risk factors like smoking, alcohol, drugs or overeating
etc.
Leisure: includes how you play, relax, stimulate, or enjoy yourself; activities for rest,
recreation, fun and creativity.
Placing an X in the appropriate spot on the Bull’s Eye – how close to the target are you living in terms
of your values? This exercise is not about being ‘right’ or ‘wrong’ but about making an honest
appraisal of your life and thinking about whether or not you want to make any changes.
Remember that it is likely that some of your values will probably change with time, and this will
become more and more apparent as you continue in recovery and start to re-evaluate what is
important to you. So if you find that what was important to you when you were at school, or
starting work is less significant now, that's OK. Be prepared to make an adjustment in your life to
allow for these changes.
Step 7 - Worksheet 18: Cultivating Positive Affirmations and Vision. The purpose of this final task is
to help each person recognise their internal and external values and to begin to develop positive
affirmations.
Step 8 – Finish the group with the 3-Minute Breathing Space
1. AWARENESS
Come into the present moment by deliberately adopting an upright and dignified posture. If
possible, close your eyes. Then notice:
“What is my experience right now… in bodily sensation…in feelings...in thoughts?”
Acknowledge and register your experience, even if it is unwanted. Allow yourself to be present, to
meet yourself, gently and with acceptance.
2. GATHERING
Then, gently bring your full attention to breathing, to each breath in and to each breath out, as they
follow, one after the other. If sound is a better anchor for you, then gently bring your awareness to
the sound around you.
Use your breath (or sound) as an anchor to bring you into the present and help you tune into a state
of awareness and stillness.
3. EXPANDING
Gently expand the field of your awareness around your breathing, so that it includes a sense of the
body as a whole… your posture … and facial expression.
© Lynne E. Magor-Blatch & James A. Pitts
Page 81
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Now gently bring your attention back into the room, and when you are ready, open your eyes.
Move your head from side to side, lift your shoulders, and let them drop. Stretch as you stand up,
and when you have stretched, sit back down again. How do you feel?
The breathing space provides a way to step out of automatic pilot mode and reconnect with the
present moment. The key skill using Mindfulness Based Cognitive Therapy (MBCT) is to maintain
awareness in the moment. Nothing else.
No homework tasks are provided with this module, since Module 7 on Relapse Prevention may not
be presented directly following Module 6.
Page 82
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Module 7.
Aim: To develop a coping plan and relapse prevention strategies for high risk situations.
Materials needed for Module 7:
·
·
·
·
Tip Sheet 12: Ten Most Common Relapse Dangers and High-Risk Situations
Worksheet 19: My Relapse Dangers
Worksheet 20: Problem Solving
Worksheet 21: Relapse Prevention Plan
Key elements of Module 7.
Step 1 – Start the group with the 3-Minute Breathing Space
1. AWARENESS
Come into the present moment by deliberately adopting an upright and dignified posture. If
possible, close your eyes. Then notice:
“What is my experience right now… in bodily sensation…in feelings...in thoughts?”
Acknowledge and register your experience, even if it is unwanted. Allow yourself to be present, to
meet yourself, gently and with acceptance.
2. GATHERING
Then, gently bring your full attention to breathing, to each breath in and to each breath out, as they
follow, one after the other. If sound is a better anchor for you, then gently bring your awareness to
the sound around you.
Use your breath (or sound) as an anchor to bring you into the present and help you tune into a state
of awareness and stillness.
3. EXPANDING
Gently expand the field of your awareness around your breathing, so that it includes a sense of the
body as a whole… your posture … and facial expression.
Now gently bring your attention back into the room, and when you are ready, open your eyes.
Move your head from side to side, lift your shoulders, and let them drop. Stretch as you stand up,
and when you have stretched, sit back down again. How do you feel?
The breathing space provides a way to step out of automatic pilot mode and reconnect with the
present moment. The key skill using Mindfulness Based Cognitive Therapy (MBCT) is to maintain
awareness in the moment. Nothing else.
Step 2 – This module will focus on assisting clients to anticipate potential high risk situations that
might lead to a lapse and to develop concrete coping plans for each of these situations. It is also
important to develop a plan for what to do in the event of an unexpected high risk situation arising.
© Lynne E. Magor-Blatch & James A. Pitts
Page 83
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Research studies and clinical experience have shown commonalities across relapse situations, with
personal issues, including family relationships; issues of social interaction and drug-related concerns
all nominated as triggers to relapse (Magor-Blatch & Rickwood, 1998).
Ask the group members to state what they think are the most common relapse dangers they face in
their recovery. Review the most common categories of relapse dangers that we know about from
clinical work and research (Lee, et.al., 2007). These relapse dangers include:
· Upsetting or negative emotional states (anger, anxiety, boredom, depression, guilt,
loneliness, etc.).
· Social pressures to get stoned or use chemicals.
· Interpersonal problems or relationship conflicts.
· Lack of social supports or a recovery network.
· Inability to solve problems or manage stress.
· Strong cravings or urges to use drugs, including alcohol.
· Lack of structure in daily life or involvement in a regular program of recovery.
· Positive feelings and a desire to celebrate.
· The coexistence of a major psychiatric disorder along with the addiction.
· Failure to follow through with a recovery program and attend counselling sessions and
self-help groups (NIDA, 2003).
Distribute Worksheet 19: My Relapse Dangers. A vital step in preventing relapse is to identify high
risk situations in advance, and to prepare for them.
Remember: We don’t practice fire drills so that we can go around lighting
fires, but so that we know what to do to protect ourselves should a fire
break out.
As clients adjust to new lives without drugs, develop relationships and take
on new responsibilities, life will become stressful. In the past, alcohol and
other drugs have been part of the person’s coping mechanism. Without
them, new ways of coping need to be developed.
Ask the group: “What kinds of people/situations/places/things will make it difficult for you in the
future? What situations do you consider to be high-risk? How do you know what the warning signs
are? Remember, relapse doesn’t just occur when you pick up, but sometime before. How will you
begin to recognise the warning signs?”
Ask each group member to identify two personal relapse dangers and coping strategies to handle
them. Have each member review their answers with others in the group. Ask other group members
to give feedback to the member who is sharing their relapse dangers and coping strategies.
Provide Tip Sheet 12: Ten Most Common Relapse Dangers and High-Risk Situations to group
members and ask what are the relapse dangers with which they identify. Discuss ways to cope with
common relapse dangers without using.
Step 3 - Developing a coping plan, which might include:
• A list of emergency numbers.
• A reminder of negative consequences of using (e.g., on a card that the client can keep in
their wallet and read when needed).
•
A set of positive thoughts that will assist in maintaining gains (e.g., on a card).
• A set of reliable distracters, at least some of which need to be immediately accessible.
Page 84
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
•
A list of safe places to ‘ride out’ a crisis (Lee, et.al., 2003).
Step 4 - The basic steps in Problem Solving are:
1. Recognise the problem.
2. Identify and specify the problem.
3. Consider various approaches to solving the problem.
4. Select the most promising approach.
5. Assess the effectiveness of the approach.
6. If ineffective, select another approach and assess.
Use Worksheet 20: Problem Solving. Ask clients to identify two problems, one that is closely related
to past drug use and one less related and work through the problem solving steps for each.
Step 5 - Relapse prevention
Use Worksheet 21: Relapse Prevention Plan to identify early warning signs of relapse. These can be
based on an analysis of previous relapses, but may also relate to the anticipation of new situations in
recovery that may be uncomfortable. List the general coping strategies which the person already
has in place, and the rewards for not using that these offer.
However, not all situations can be anticipated in advance, therefore it is useful to think about some
general coping strategies that can be called on – like calling a friend, a peer, a sponsor. These will be
the skills that are most effective to develop. Identify any additional skills required to help prevent
relapse and ask the group to offer suggestions about how to acquire these. To consolidate the use
of the plan, discuss with the client(s) when to use the plan and how to monitor early warning signs
(Lee et al., 2003).
Step 6 - Maintaining Recovery
1. Stress the importance of keeping recovery plans up-to-date and working at long-term
recovery.
2. Discuss the importance of continuing to adhere to one’s recovery goals and how effective
this can be in maintaining abstinence.
3. Reinforce the need for continuing to participate in self-help groups and using the ‘tools’ of
recovery on a daily basis.
4. Ask the group members to identify the benefits of ongoing participation in a recovery
program following completion of professional treatment.
Some examples include:
· Receiving continued help and support from others in recovery.
· Actively working at a program of recovery reduces relapse risk.
· Involvement in recovery, especially support groups, is a constant reminder of the
seriousness of addiction and the importance of maintaining recovery.
· Staying sober puts the recovering person in a position in which he or she is able to
continue to make positive changes in self and lifestyle.
· Many problems and issues emerge over time, even if one is sober from alcohol or
clean from drugs. Participating in a recovery program can make the person feel
better prepared to handle these issues or problems.
© Lynne E. Magor-Blatch & James A. Pitts
Page 85
Group Intervention for Amphetamine-Type Stimulants (GIATS)
5. Discuss the length of time one should stay involved in a recovery program such as AA or NA.
This varies considerably among recovering individuals, with many staying involved for years
or even throughout their lives. Remember, pushing through the reluctance and barriers to
attending support groups is important. The excuses (“I’m different”, “I don’t really identify”,
“My issues/story are nothing like theirs”) are often just the excuses we use to keep ourselves
on the outer – and ultimately to feel so bad that we give ourselves permission once again to
use.
6. Ask the group to identify the ‘tools’ of recovery that they can use on a regular basis, once
they are finished with the group sessions. These tools may include the following:
· Attending AA, NA, or other self-help meetings.
· Talking with a sponsor or other members of self-help programs.
· Sharing social or recreational activities with friends.
· Avoiding high-risk people, places, or situations when possible.
· Attending aftercare group counselling sessions or talking individually with a
counsellor or therapist.
· Using techniques learned to fight off thoughts of drinking alcohol or using other
drugs or to fight off strong cravings.
· Using positive affirmations by reminding oneself of the benefits of sobriety and that
all the time and effort put into is worthwhile.
· Getting physical exercise.
· Focusing on one of the 12 steps.
· Repeating and thinking about a recovery slogan.
· Reading specific recovery literature or a meditation guide.
· Writing in a recovery journal or workbook.
· Participating in pleasant activities that don’t involve alcohol or other drugs.
· Doing something nice for someone else as a way of ‘giving back’.
· Reviewing one’s plan for recovery at the beginning of each day.
· Evaluating how the day went to review positive growth and identify problems
needing attention.
· Regularly reviewing relapse warning signs to catch them early.
7. Group members can also state how these various recovery tools can help their ongoing
recovery, such as the following:
· Helping to identify problems and warnings signs early.
· Becoming aware of behaviours and strategies to help in recovery.
· Using the support of others in recovery.
Page 86
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Section 4:
Worksheets
© Lynne E. Magor-Blatch & James A. Pitts
Page 87
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Page 88
Lynne E. Magor-Blatch & James A. Pitts
1.
2.
© Lynne E. Magor-Blatch & James A. Pitts
Week 5
Week 4
Week 3
Week 2
Week 1
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Provide anchors for the client by first filling in public holidays, significant personal events and other dates on the calendar.
Assist the client to work back from last day of use and complete ALL drug use for each day.
Sunday
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 1: Timeline Follow Back
Page 89
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 2: Stages of Change Ladder
The rungs on this ladder can be used to represent where you are now in regard to your substance
use. Tick the rung that best describes where you are right now.
Maintenance
Action
Preparation
Contemplation
Precontemplation
I’m doing OK in recovery. Using my supports
and maintaining my goals
I’m in recovery and learning about myself
and what I need to do to continue
I have made real plans to quit or cut down and
I’m getting ready for treatment
I think I might need to quit or cut down,
but I'm not sure I want to or that I’m ready for it
I'm happy using and don't feel
the need to quit or cut down
Adapted from Lee et al. (2007), and from original work of Biener & Abrams (1991)
Page 90
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 3: Psychosis screener
The Psychosis Screener is clinician administered.
Only ask the supplementary questions (1a, 2a and 3a) if the client answers YES to the main
question.
1. In the past 12 months, have you felt that your thoughts were being directly interfered with or
controlled by another person?
q
Yes (go to 1a)
q No (go to 2)
1a. Did it come about in a way that many people would find hard to believe, for instance, through
telepathy?
q
Yes
q No
2. In the past 12 months, have you had a feeling that people were too interested in you?
q
Yes (go to 2a)
q No (go to 3)
2a. In the past 12 months, have you had a feeling that things were arranged so as to have a special
meaning for you, or even that harm might come to you?
q Yes
3. Do you have any special powers that most people lack?
q
No
q Yes (go to 3a) q No (go to 4)
3a. Do you belong to a group of people who also have these special powers?
q
Yes (-1 point)
q
4. Has a doctor ever told you that you may have schizophrenia?
q
Yes
q
No
No
Scoring:
Each question answered 'yes' is scored 1 point, except question 3a which is scored -1 if answered 'yes'.
Add each score. A cumulative score of 3 or more indicates potential presence of significant psychotic
symptoms.
Source: Lee, et.al. (2007); adapted from Degenhardt, Hall, Korten, Morgan, and Jablensky (2005).
© Lynne E. Magor-Blatch & James A. Pitts
Page 91
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 4: Lifestyle issues causing problems in my life
These are the lifestyle issues which some people have nominated as the reason to give up their use
of ATS (methamphetamine and other amphetamine-type stimulants). Put a tick in the box
opposite each of the factors if they apply to you – i.e., it was one of the reasons you decided to
seek treatment.
Argued with others
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
Page 92
Lost my temper
Had reduced work/study performance
Did something under the influence of drugs that I later regretted
Took sick leave/did not attend classes
Couldn’t remember what happened the night before
Damaged some of my own property
Had unprotected sex
No money left for any luxuries
Passed out
Upset a family relationship
Stole property
No money for food or rent
Damaged a friendship
Got into debt/owing money
Ended a personal relationship
Got arrested
Physically hurt someone else
Got a traffic ticket
Spent some nights sleeping rough (i.e., living on the streets)
Sacked / lost business /quit study course
Had a car crash
Had sex and later regretted it
Charged with a driving offence
Was kicked out of where I was living
Physically hurt myself
Overdosed on drugs
Was sexually harassed
Was sexually assaulted
Any others? Please record any other issues on the back of this form.
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 5: Decisional balance
When we think about making changes, most of us don’t really consider all aspects of the problem –
so we don’t get a full picture. Often we think about what we ‘should’ do, or we avoid doing the things
we don’t like doing, or just get confused, or become overwhelmed. Thinking through the pros and
cons of both changing and of not changing, is one way of making sure that we are weighing up both
sides. It can also help us to maintain the focus when things become hard. Notice where the balance
lies – have you found reasons to stay the same, or are there reasons to make a change?
Things I like about drinking or using
Things I don’t like about drinking or using
Things I don’t like about stopping drinking
or using
Things I like about stopping drinking or
using
REASONS FOR STAYING THE SAME
REASONS FOR MAKING A CHANGE
Adapted from Miller and Rollnick (2003). Motivational Interviewing: Preparing people for change. (2nd ed). New York.
The Guilford Press.
© Lynne E. Magor-Blatch & James A. Pitts
Page 93
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 6: Vitality vs. Suffering
Permission given to adapt from Russ Harris (2007) www.actmindfully.com.au
YOUR STRUGGLES: What are the main thoughts and feelings you struggle with? What thoughts and
feelings pull you into a struggle with life, health, happiness, yourself, or others? Write these down inside the two
circles. What do you do when these thoughts and feelings show up? On the top half of the page, list things you
do that increase your VITALITY – and on the bottom half, list things you do that increase your SUFFERING.
VITALITY: (list all the positive things you have done when these thoughts and feelings showed up – i.e.,
things that improved your life, health, happiness, relationships and vitality in the long term). Remember,
sometimes these things might seem hard in the short term (like you are increasing your suffering instead of
vitality) but they will be increasing your vitality over time.
Mind
Thoughts, memories, beliefs,
worries, self-judgements
Body
Feelings, sensations,
urges, cravings,
symptoms of physical illness
SUFFERING: (list all the negative things you have done when these thoughts and feelings showed up – i.e.,
things that wasted your time, energy, and money, damaged your health, hurt your relationships, or worsened
your life in the long term). Remember, sometimes these feel like they are increasing your vitality – but that
will be just in the short term, in the long term they actually increase your suffering.
Page 94
Lynne E. Magor-Blatch & James A. Pitts
Painful thoughts, feelings, urges, memories
that showed up today.
What I did that lead to VITALITY
(improving life, health, wellbeing in the long
term.
What I did that lead to SUFFERING
(worsening life, health, wellbeing in the long
term.
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 7: Vitality vs. Suffering Diary
Permission given to use by Russ Harris (2007) www.actmindfully.com.au
© Lynne E. Magor-Blatch & James A. Pitts
Page 95
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 8: Unhelpful thinking patterns
1. Catastrophising – People with this pattern of thinking tend to give too much meaning to
situations. So, you exaggerate the importance of things - making mountains out of mole hills or
convincing yourself that if something goes wrong it will be totally unbearable and intolerable.
2. Mind reading – This means making assumptions about how others feel, arbitrarily concluding
that someone is reacting negatively to you, without checking this out.
3. Overgeneralisation - Making broad ‘always’ or ‘never’ statements. You see a single negative
event as a never-ending pattern of defeat.
4. Labeling and Mislabeling - This is an extreme form of overgeneralisation. Instead of describing
your error, you attach a negative label to yourself: “I’m a loser.” When someone else’s behaviour
rubs you the wrong way, you attach a negative label to him: “He’s a pathetic wimp.” Mislabeling
involves describing an event with language that is highly coloured and emotionally loaded.
5. Selective abstraction - Focusing on one small detail and interpreting the entire experience by
that detail.
6. Personalisation - Excessively blaming yourself for events over which you did not have complete
control. You see yourself as the cause of some negative external event which in fact you were not
primarily responsible for. This means that you will often confuse facts with feelings – if someone
else is in a bad mood, you will think it’s something you did – when it may have nothing to do with
you at all.
7. ‘Should’ fallacies - You try to motivate yourself with ‘shoulds’ and ‘should nots’, as if you had to
be whipped and punished before you could be expected to do anything. ‘Musts’ and ‘oughts’ are
also offenders. "I should be better”. The emotional consequence is guilt. ‘Should’ statements
directed to others result in anger, frustration, and resentment. “They should care about me
much more than they do." This type of thinking often leads to feelings of guilt and sets you up to
be disappointed, particularly if the thoughts are unreasonable.
8. Minimisation - Reducing an important event into something less important. This includes
inappropriately shrinking things until they appear tiny (your own desirable qualities or the
problems in your life so that you don’t have to face them). This is also called the ‘binocular trick’.
9. Black and white thinking – This is All-Or-Nothing Thinking - You see things in black-and-white
categories, so that things are either all good or all bad, with nothing in between – or no balance.
Do you have strict rules about yourself or your life? Are you rigid in your thinking? If your
performance falls short of perfect, do you see yourself as a total failure?
10.Mental Filter - You pick out a single negative defeat and dwell on it exclusively so that your vision
of reality becomes darkened, like the drop of ink that colors the entire glass of water.
11.Disqualifying the positive - You dismiss positive experiences by insisting they ‘don’t count’ for
some reason or other. In this way you can maintain a negative belief that is contradicted by your
everyday experiences.
Page 96
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
12.Jumping to conclusions - You make a negative interpretation even though there are no definite
facts that convincingly support your conclusion. This means that you may also act like a mind
reader or a fortune teller believing that you know what the other person is feeling or thinking
without checking it out. You also think that things will turn out badly, and that this will probably
always be the case.
13.The fortune teller error - You anticipate that things will turn out badly, and you feel convinced
that your prediction is an already-established fact.
14.Emotional Reasoning - You assume that your negative emotions necessarily reflect the way
things really are: “I feel it, therefore it must be true”.
© Lynne E. Magor-Blatch & James A. Pitts
Page 97
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 9: Self monitoring record
This diary will help you understand the differences between thoughts and feelings.
1. Start with A. This is called the Activating Event.
2. Then go to B, which stands for Belief, and write down your thoughts.
3. Now go to C. What were the Consequences?
A - Activating Event
B – Belief
C - Consequences Write down the
Write down a situation, an event,
Write down your thoughts. Ask
words that describe how you feel.
thought or mental picture that
yourself, “What was I thinking?”
Underline the one that is most
made you feel upset.
associated with the activating
event. Find the most distressing
hot thought and underline it.
4. Now think back to the Unhelpful Thinking Styles that we have discussed. Do you recognise any unhelpful
thinking styles you might have been using?
5. Finally, look at D, which stands for Detective Work and Disputation. In the first column, think about the
hot thought which you recorded under Consequences.
6. Then go to the second D column – Disputation – What other ways are there of viewing this situation?
Unhelpful Thinking Styles
D - Detective Work Think about
D – Disputation
Do you recognise any unhelpful
the hot thought which you
What other ways are
thinking styles you might have
recorded under Consequences.
there of viewing this situation? Is
been using? (e.g., Mental filter,
Ask yourself, “What is the factual
there another way of looking
Personalisation, Catastrophising
evidence for and against my hot
at it, or another explanation?
etc?)
thought?” Record this.
Page 98
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 10: Understanding how we experience Feelings
From the list of feelings below,
choose a feeling that you have
experienced in the past week.
Mark on the diagram where in
your body you experienced the
feeling. Choose an
appropriate coloured pencil or
crayon to mark this on the
diagram. For example, if you
chose ANGRY perhaps your
heart raced, your face turned
red or you began to sweat.
Jealous
Glad
Embarrassed
Depressed
Relieved
Fearful
Anxious
Disappointed
Tired
Content
Hurt
Pride
Amused
Grateful
© Lynne E. Magor-Blatch & James A. Pitts
Sad
Guilty
Disgusted
Thoughtful
Happy
Disturbed
Worried
Lonely
Shame
Surprised
Nervous
Lost
Angry
Confused
Pride
Excitement
Miserable
Bitter
Calm
Joy
Helpless
Page 99
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 11: Feelings of Anger, Loss, Shame and Guilt
Anger: Some of the positive ways I can express my feelings of anger
Loss: Thinking back over my life, how have some of my losses affected me?
Shame: This is my tendency to feel bad about myself following a specific event.
Guilt: I feel guilty when I feel bad about a specific behaviour or action.
Page 100
Lynne E. Magor-Blatch & James A. Pitts
Were you aware of the
pleasant feelings while
the event was
happening?
Yes.
What was the
experience?
Example:
Working in the garden stopping, hearing a bird
sing.
Lightness across the face,
aware of shoulders
dropping, uplift of
corners of mouth.
How did your body feel,
in detail, during this
experience?
"That's good."
"How lovely (the bird)."
"It's so nice to be
outside."
What moods, feelings
and thoughts
accompanied this event?
It was a small thing but
I'm glad I noticed it.
What thoughts are in
your mind now as you
write this down?
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 12: Pleasant Events Calendar
Be aware of a pleasant event at the time it is happening. Use the questions to focus your awareness
on the details of the experience as it is.
Adapted from Zindel Segal, Mark Williams, and John Teasdale (2002), Mindfulness-Base Cognitive Therapy for Depression:
A New Approach to Preventing Relapse.
© Lynne E. Magor-Blatch & James A. Pitts
Page 101
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 13: Anxious Automatic Thoughts Questionnaire
Listed below are a variety of thoughts that pop into people's heads.
·
Read each thought carefully and indicate how frequently, if at all, the thought occurred to
you over the last week, by circling the answer in the left column.
·
Then, indicate how strongly, if at all, you tend to believe that thought when it occurs by
circling your answer in the right column.
FREQUENCY
DEGREE OF BELIEF
1 = "not at all"
1 = "not at all"
ITEMS
5 = "all the time"
5 = "totally"
1
2
3
4
5
1.
When people look at me they are examining what I do
1
2
3
4
5
1
2
3
4
5
2.
If I get criticized it means that I am wrong.
1
2
3
4
5
1
2
3
4
5
3.
If I make a mistake that means that I am stupid.
1
2
3
4
5
1
2
3
4
5
4.
If I don't agree with people they won't like me.
1
2
3
4
5
1
2
3
4
5
5.
To be a good person I have to be nice to everyone.
1
2
3
4
5
1
2
3
4
5
6.
If someone is hurt or offended by what I do, this means
1
2
3
4
5
I am a bad person.
1
2
3
4
5
7.
If I show emotion it means that I am weak.
1
2
3
4
5
1
2
3
4
5
8.
People will think that there is something wrong with
1
2
3
4
5
1
2
3
4
5
me if they see that I am anxious.
1
2
3
4
5
9.
The opinions of other people about me are very
important.
1
2
3
4
5
10. I'm afraid that I look or sound silly to other people
1
2
3
4
5
1
2
3
4
5
11. I can tell that people will evaluate me negatively.
1
2
3
4
5
1
2
3
4
5
12. I have to be very careful about what I say in case I
1
2
3
4
5
offend someone.
1
2
3
4
5
13. Approval is very important to me.
1
2
3
4
5
1
2
3
4
5
14. Being anxious is a sign of weakness.
1
2
3
4
5
1
2
3
4
5
15. When people see me behave like this they will talk
1
2
3
4
5
1
2
3
4
5
badly of me to others.
1
2
3
4
5
16. If someone is late, I assume there has been an
accident.
We begin to recognise unrealistic, frightening anxiety producing thoughts and learn simply to be
present with them without attaching to them and believing them, ignoring them, or judging them
and pushing them away.
Taylor (2008); Adapted with permission from Hollon and Kendall (1980).
Page 102
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 14: Coping Statements for Anxiety
Purpose: to put a stop to the thoughts that lead to anxiety, and to replace those thoughts with
realistic, rational thoughts. When these self-statements are practiced and learned, your brain takes
over automatically. This is a form of conditioning, meaning that your brain chemistry
(neurotransmission) actually changes as a result of your new thinking habits.
The first thing to do is to put a stop to the thoughts. Remind yourself that the thoughts you are
having are not healthy or helpful and you have decided to move in a better direction and learn to
think differently. Then, pick two or three statements from the list below that seem to help you, and
repeat them to yourself OUT LOUD each day. (You don’t have to believe them fully yet – that will
happen later).
When Anxiety is Near: General Statements:
1. I’m going to be all right. My feelings are not always rational. I’m just going to relax, calm
down, and everything will be all right.
2. Anxiety is not dangerous - it’s just uncomfortable.
3. Right now I have some feelings I don’t like. They’re not real, because they are disappearing.
I will be fine.
4. Right now I have feelings I don’t like. They will be over soon and I’ll be fine. For now, I am
going to focus on doing something.
5. That picture (image) in my head is not a healthy or rational picture. Instead, I’m going to
focus on something healthy like _________________________.
6. I’ve stopped my negative thoughts before and I’m going to do it again now. I am becoming
better and better at deflecting these negative thoughts and that makes me happy.
7. So I feel a little anxiety now, SO WHAT? It’s not like it’s the first time. I am going to take
some deep breaths and keep on going. This will help me continue to get better."
Statements to use when preparing for a Stressful Situation:
1. I’ve done this before so I know I can do it again.
2. When this is over, I’ll be glad that I did it.
3. This may seem hard now, but it will become easier and easier over time.
4. I think I have more control over these thoughts and feelings than I once imagined. I am very
gently going to turn away from my old feelings and move in a new, better direction.
Statements to use when I feel overwhelmed:
1. I can be anxious and still focus on the task at hand. As I focus on the task, my anxiety will go
down.
2. Anxiety is an old habit pattern that my body responds to. I am going to calmly change this
old habit. I feel some peace, despite my anxiety, and this peace is going to grow and grow.
As my peace and security grow, then anxiety and panic will have to shrink.
3. At first, my anxiety was powerful and scary, but as time goes by it doesn’t have the hold on
me that I once thought it had. I am moving forward gently all the time.
4. I don’t need to fight my feelings. I realize that these feelings won’t be allowed to stay
around very much longer. I just accept my new feelings of peace, contentment, security,
and confidence.
5. All these things that are happening to me seem overwhelming. But I’ve caught myself this
time and I refuse to focus on these things. Instead, I’m going to talk slowly to myself, focus
away from my problem, and continue with what I have to do. In this way, my anxiety will
shrink and disappear.
© Lynne E. Magor-Blatch & James A. Pitts
Page 103
Group Intervention for Amphetamine-Type Stimulants (GIATS)
PERSONAL VALUES
Card Sort
IMPORTANT TO ME
VERY IMPORTANT
TO ME
NOT IMPORTANT TO
ME
ACCEPTANCE
ACCURACY
W.R. Miller, J. C’de Baca, D.B.
Matthews, P.L.
Wilbourne
University of New Mexico, 2001
to be accepted as I am
1
to be accurate in my opinions and
beliefs
2
ACHIEVEMENT
to have important accomplishments
3
ADVENTURE
to have new and exciting experiences
4
ATTRACTIVENESS
AUTHORITY
to be physically attractive
5
Page 104
to be in charge of and responsible
for others
6
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
AUTONOMY
BEAUTY
to be self-determined and independent
7
to appreciate beauty around me
8
CARING
to take care of others
9
CHALLENGE
to take on difficult tasks and problems
10
CHANGE
to have a life full of change and variety
COMFORT
to have a pleasant and comfortable life
12
11
COMMITMENT
to make enduring, meaningful
commitments
13
COMPASSION
to feel and act on concern for others
14
CONTRIBUTION
to make a lasting contribution
in the world
15
© Lynne E. Magor-Blatch & James A. Pitts
COOPERATION
to work collaboratively with others
16
Page 105
Group Intervention for Amphetamine-Type Stimulants (GIATS)
COURTESY
CREATIVITY
to be considerate and polite
toward others
17
to have new and original ideas
18
DEPENDABILITY
to be reliable and trustworthy
19
DUTY
to carry out my duties and obligations
20
ECOLOGY
EXCITEMENT
to live in harmony with the environment
21
to have a life full of thrills and
stimulation
22
FAITHFULNESS
FAME
to be loyal and true in relationships
23
to be known and recognised
24
FAMILY
FITNESS
to have a happy, loving family
25
Page 106
to be physically fit and strong
26
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
FLEXIBILITY
FORGIVENESS
to adjust to new circumstances easily
27
to be forgiving of others
28
FRIENDSHIP
FUN
to have close, supportive friends
29
to play and have fun
30
GENEROSITY
GENUINENESS
to give what I have to others
31
to act in a manner that is
true to who I am
32
GOD’S WILL
GROWTH
to seek and obey the will of God
33
to keep changing and growing
34
HEALTH
HELPFULNESS
to be physically well and healthy
35
© Lynne E. Magor-Blatch & James A. Pitts
to be helpful to others
36
Page 107
Group Intervention for Amphetamine-Type Stimulants (GIATS)
HONESTY
HOPE
to be honest and truthful
37
to maintain a positive and
optimistic outlook
38
HUMILITY
HUMOUR
to be modest and unassuming
39
to see the humorous side of
myself and the world
40
INDEPENDENCE
to be free from dependence on others
41
INDUSTRY
to work hard and well at my life tasks
42
INNER PEACE
to experience personal peace
43
INTIMACY
to share my innermost experiences
with others
44
JUSTICE
KNOWLEDGE
to promote fair and equal treatment
for all
45
Page 108
to learn and contribute valuable
knowledge
46
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
LEISURE
LOVED
to take time to relax and enjoy
47
to be loved by those close to me
48
LOVING
MASTERY
to give love to others
49
to be competent in my everyday
activities
50
MINDFULNESS
MODERATION
to live conscious and mindful
of the present moment
to avoid excesses and find a
middle ground
52
51
MONOGAMY
to have one close, loving relationship
53
NON-CONFORMITY
to question and challenge authority
and norms
54
NURTURANCE
OPENNESS
to take care of and nurture others
55
© Lynne E. Magor-Blatch & James A. Pitts
to be open to new experiences,
ideas, and options
56
Page 109
Group Intervention for Amphetamine-Type Stimulants (GIATS)
PASSION
ORDER
to have deep feelings
about ideas,
to have a life that is well-ordered
and organised
activities, or people
58
57
PLEASURE
POPULARITY
to feel good
59
to be well-liked by many people
60
POWER
to have control over others
61
PURPOSE
to have meaning and direction in my life
62
RATIONALITY
REALISM
to be guided by reason and logic
63
to see and act realistically
and practically
64
RESPONSIBILITY
RISK
to make and carry out
responsible decisions
65
Page 110
to take risks and chances
66
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
ROMANCE
SAFETY
to have intense, exciting
love in my life
67
to be safe and secure
68
SELF-ACCEPTANCE
to accept myself as I am
69
SELF-CONTROL
to be disciplined in my own actions
70
SELF-ESTEEM
SELF-KNOWLEDGE
to feel good about myself
to have a deep and honest
understanding
of myself
72
71
SERVICE
to be of service to others
73
SEXUALITY
to have an active and satisfying sex life
74
SIMPLICITY
to live life simply, with minimal needs
75
© Lynne E. Magor-Blatch & James A. Pitts
SOLITUDE
to have time and space where I can
be apart from others
76
Page 111
Group Intervention for Amphetamine-Type Stimulants (GIATS)
SPIRITUALITY
STABILITY
to grow and mature spiritually
to have a life that stays fairly
consistent
78
77
TOLERANCE
to accept and respect those who
differ from me
79
TRADITION
to follow respected patterns of the past
80
VIRTUE
WEALTH
to live a morally pure and excellent life
81
to have plenty of money
82
WORLD PEACE
Other Value:
Other Value:
Other Value:
to work to promote peace in the world
83
Page 112
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 15: Ranking of Personal Values Card Sort
Card
eg. Card 1
Value
43. Inner peace
What it means to me
I’ve wanted this for so long, my life has been a real mess.
If I had inner peace then it would mean that everything
else must be in place.
Card 1
Card 2
Card 3
Card 4
Card 5
Card 6
Card 7
Card 8
Card 9
Card 10
Card 11
Card 12
Card 13
Card 14
Card 15
© Lynne E. Magor-Blatch & James A. Pitts
Page 113
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 16: Personal Values Exercise
This exercise will help you to think through what areas of life are important to you. This means both
your values as well as the things that you value. For each value take some time to identify how you
would like to live the particular value and write it down on the second sheet. This can be a difficult
exercise as it is easy to say that family is important, but it can be hard to articulate what that means
to you personally.
Values are life directions rather than goals. While goals can be achieved, values cannot. Values are
the things we hold dear, close to our hearts. The things that are most important to us.
So a value might be to be a more considerate partner and a goal may be to spend more time with
my partner.
1. Relationships
a. Family (other than partner or parenting): Describe what sort of brother, sister, son,
daughter, etc that you would like to be. How would you ideally like to treat others in your
family?
b. Relationship/Intimacy: Think about the ideal relationship. What would your role be and
how would it fit with that of your partner?
c. Parenting: How would you want your children to describe you? Imagine they are talking
about parenting as adults, what would you like them to have learnt from you?
d. Friends/Social Life: How could you be a best friend? Do you know someone who you look
up to in this way? What is it about them that you admire?
2. Work
a. Workplace/career: What would be your ideal job? Not the name of the job but the type of
work you would do and why it would be your ideal. What would you like your work
relationships to be like? What sort of co-worker would you want to be?
b. Education/Training: What would you like to be studying, or what area of skills development
is important to your future?
3. Personal growth/Health
a. Think of someone who has grown through difficult times, what do you admire about them?
What people in public life, sports people for example, do you admire, and why?
b. Physical self-care: How would you ideally look after yourself? What about this is important
to you? Think about things like sleep, exercise, smoking, your appearance, health problems.
c. Spirituality/religion: Is this important to you? How would you like to practice your
spirituality/religion?
4. Leisure/fun and activity: What would your ideal weekend, holiday, day off, evening, look like if
you were living life in recovery?
Page 114
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Area
Description
1. Relationships
a. Family (other than
partner or parenting)
b. Relationship/Partner
c. Parenting
d. Friends/Social life
2. Work
a. Workplace/career
b. Education/Training
3. Personal Growth/Health
a. Physical Self Care
(diet, exercise, sleep)
b. Spirituality/Religion
4. Leisure/fun & activity
© Lynne E. Magor-Blatch & James A. Pitts
Page 115
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 17: Values ‘Bull’s Eye’
YOUR VALUES: What really matters to you, deep in your heart? What do you want to do with your
time on this planet? What sort of person do you want to be? What personal strengths or qualities do
you want to develop?
1. Relationships: includes your partner, children, parents, relatives, friends, and other social
contacts.
2. Work/Education: includes workplace, career, education, skills development, etc.
3. Personal Growth/Health: may include religion, spirituality, creativity, life skills, exercise, nutrition,
and/or addressing health risk factors like smoking, alcohol, drugs or overeating etc
4. Leisure: how you play, relax, stimulate, or enjoy yourself; activities for rest, recreation, fun and
creativity.
THE BULL’S EYE: make an X in each area of the bull’s eye to represent where you stand today.
“I am acting very inconsistently
with my values”
Work/Education
Relationships
“I am
living
fully by
my
values”
Leisure
Personal growth/Health
Adapted with permission from © Russ Harris, 2007 (adapted from Tobias Lundgren’s "Bull’s Eye")
www.actmindfully.com.au
Page 116
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 18: Cultivating Positive Affirmations and Vision
We can use the values in the chart to help guide us in our actions and decisions about how we might
be leading our lives, and where we might like to be doing something different. This might be difficult
in early recovery, and maybe you’re not used to thinking about your positive attributes. This exercise
is designed to help you recognise some of these things, and to start to appreciate these qualities. As
you continue in recovery the list will grow and change. Don’t worry if there are only one or two
things written in each box. The values you record will help you guide your actions and your decisions
about how you lead your life from this point on.
Internal Values
External Values
Talents
What you naturally do well, without thinking too
much about it
Knowledge
Specialist knowledge
Passions
What lights me up, makes me shine
Contacts
The people I know
Purpose
What drives me and brings meaning to my life
Character
Unique things about me that I notice and others
notice
Adapted from Liana Taylor (2008); Adapted with permission from Hollon and Kendall (1980).
© Lynne E. Magor-Blatch & James A. Pitts
Page 117
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 19: My Relapse Dangers
The following are examples of situations which pose a danger to many people in recovery. Read
through these and then write in the space below the situations that pose the greatest relapse
danger to you at this time. These are the ones that you should avoid if at all possible. If you can’t
avoid them, then accept the need to plan carefully and get as much support as you can.
1. Relapse Danger #1: Being bored and missing the action of partying and using.
Steps I can take to handle this situation without using drugs:
· Keep involved in NA meetings and activities so I can hook up with other clean people to learn
what they are doing to cope with boredom.
· Call my sponsor or other NA friends when my boredom starts me thinking about using.
· Make a plan for every weekend because this is the time I feel most bored.
My Relapse Danger #1:
Steps I can take to handle this situation without using:
2. Relapse Danger #2: Feeling depressed about my life and how I messed it up.
Steps I can take to handle this situation without using drugs:
· Keep remembering that it will take time to get my life together after stopping using.
· Focus on the positive things I have— family, partner, learning new skills and my improved
health.
· Talk about how I feel and get support from others in the program.
My Relapse Danger #2:
Steps I can take to handle this situation without using:
Page 118
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Worksheet 20: Problem Solving
1. Identify and define the problem
· Try to state the problem as clearly as possible;
· Try to understand what maintains the problem, rather than just its cause;
· Consider the different approaches you could use to solve the problem;
· Select what you consider would be the most useful approach;
· Assess its effectiveness; and
· If needed, change the approach.
The Problem:
What maintains the
problem:
2. The best solution seems to be:
© Lynne E. Magor-Blatch & James A. Pitts
Possible approaches:
3. Assessment and review:
Page 119
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Work sheet 21: Relapse Prevention Plan
Early warning signs for relapse
1.
2.
3.
4.
5.
6.
Anticipated high risk situations
Coping strategies
Reward
General coping strategies in an emergency
Additional skills required
How to get them
Source: Lee et al., (2007)
Page 120
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
References
ACON (2006) Crystal - How crystal is taken, Aids Council of New South Wales,
http://www.acon.org.au/health/index.cfm?cat_id=103 (Accessed 28/11/06).
Alem, A., Kebede, D., & Kullgren, G. (1999). The prevalence and socio-demographic correlates of
khat chewing in Butajira, Ethiopia. Acta Psychiatr Scand Suppl. 397:84-91.
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM IV-TR), American Psychiatric Association, Washington
DC.
Anderson, B., Chen, G., Gutman, D. A., & Ewing, A.G. (1998). Dopamine levels of two classes of
vesicles are differentially depleted by amphetamine. Brain Res. 788(1-2):294-301.
Baker, A., Bucci, S., Lewin, T., Richmond, R. & Carr, V. (2005). Comparisons between psychosis
samples with different patterns of substance use recruited for clinical and epidemiological
studies. Psychiatry Research, 134, 241-250.
Baker, A., Kay-Lambkin, F., Lee, N.K., Claire, M. & Jenner, L. (2003). A brief cognitive behavioural
intervention for regular methamphetamine users. Canberra: Australian Government
Department of Health and Ageing.
Baker, A. & Lee, N.K. (2003). A review of psychosocial interventions for methamphetamine use.
Drug and Alcohol Review 22(3): 323-335.
Baker, A., Lee, N.K., Claire, M., Lewin, T.J., Grant, T., Pohlman, S., Saunders, J., Kay-Lambkin, F.,
Constable, P., Jenner, L. & Carr, V.J. (2004). Brief cognitive behavioural interventions for
regular amphetamine users: a step in the right direction. Addiction, 100, 367-378.
Baker, A., Lee, N.K. & Jenner, L. (2004). Models of intervention and care for psychostimulant users.
2nd Edition. National Drug Strategy. Monograph Series No 51. Canberra: Australian
Government Department of Health and Ageing.
Batten, S.V. & Hayes, S.C. (2005). Acceptance and Commitment Therapy in the Treatment of
Comorbid Substance Abuse and Post-Traumatic Stress Disorder. Clinical Case Studies, 4(3),
246-262.
Biener, L., & Abrams, D.A. (1991). The Contemplation Ladder: Validation of a measure of readiness
to consider smoking cessation. Health Psychology, 10(5), 360-365.
Budney, A.J., Higgins, S.T., Radonovich, K.J., & Novy, P.L. ( 2000). Adding voucher-based incentives to
coping skills and motivational enhancement improves outcomes during treatment for
marijuana dependence. Journal of Consulting and Clinical Psychology, 68(6), 1051–1061.
Carroll, K.M. (1996). Relapse prevention as a psychosocial treatment: A review of controlled clinical
trials. Experimental and Clinical Psychopharmacology, 4, 46–54.
Cooper, N. (2003). Inappropriate prescription of methylphenidate. New Zealand Medical Journal;
116(1183): U636.
© Lynne E. Magor-Blatch & James A. Pitts
Page 121
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Dawe, S. & McKetin, R. (2004). Comorbidity and psychostimulant use. In Models of Intervention and
care for psychostimulant users. (Eds. A. Baker, N. Lee, and L. Jenner). National Drug
Strategy Monograph Series.
Degenhardt, L., Hall, W., Korten, A., Morgan, V. & Jablensky A. (2005) Use of a brief screening
instrument for psychosis: results of an ROC analysis. NDARC technical report no. 210.
Sydney: National Drug and Alcohol Research Centre.
Eliany, M. (1992). Alcohol and drug consumption among Canadian youth. Canadian Social Trends,
26, 10-13.
Harris, A.D., McGregor, J.C. Perencevich, E.N., Furuno, J.P., Zhu, J., Peterson, D.E., & Finkelstein, J.
(2006). The use and interpretation of quasi-experimental studies in medical informatics.
Journal of American Medical Informatics Association, 13(1): 16–23. doi:
10.1197/jamia.M1749.
Harris, R. (2007). ACT in a Nutshell. http://www.actmindfully.com.au
Hayes, S.C., Luoma, J.B., Bond, F.W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment
therapy: Model, processes and outcomes. Behavior Research and Therapy, 44(1), 1–25.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Bissett, R., Piasecki, M., Batten, S. V., Byrd, M., & Gregg, J.
(2004). A preliminary trial of twelve-step facilitation and Acceptance and Commitment
Therapy with polysubstance-abusing methadone-maintained opiate addicts. Behavior
Therapy, 35(4), 667–688.
Hofmann, S.G., & Asmundson, G.J. (2008). Acceptance and mindfulness-based therapy: New wave or
old hat? Clinical Psychological Review, 28, 1–16.
Hofmann, S.G., Sawyer, A.T. & Fang, A. (2010.) The empirical status of the “new wave” of CBT.
Psychiatric Clinics of North America, 33(3), 701–710.
Hollon, S. D., & Kendall, P. C. (1980). Cognitive self-statements in depression: Development of an
automatic thoughts questionnaire. Cognitive Therapy and Research, 4, 383-395.
Jenner, L. & Saunders, J. (2004). Psychostimulant withdrawal and detoxification. In Models of
Intervention and care for psychostimulant users. (Eds. A. Baker, N. Lee, and L. Jenner).
National Drug Strategy Monograph Series.
Kendall, P.C., & Hollon, S. D. (1989). Anxious Self-Talk: Development of the Anxious Self-Statements
Questionnaire (ASSQ). Cognitive Therapy and Research, 13(1): 81-93.
Larson, M. (2008). Amphetamine-Related Psychiatric Disorders.
http://emedicine.medscape.com/article/289973-overview
Lee, N., Jenner, L., Kay-Lambkin, F., Hall, K., Dann, F., Roeg, S., Hunt, S., Dingle, G., Baker, A., Hides, L.
& Ritter, A. (2007). PsyCheck: Responding to mental health issues within alcohol and drug
treatment. Canberra, ACT: Commonwealth of Australia.
Page 122
Lynne E. Magor-Blatch & James A. Pitts
Group Intervention for Amphetamine-Type Stimulants (GIATS)
Lee, N., Johns, L., Jenkinson, R., Johnston, J., Connolly, K., Hall, K. & Cash, R. (2007). Clinical
Treatment Guidelines for Alcohol and Drug Clinicians. No 14: Methamphetamine
dependence and treatment. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc.
Magor-Blatch, L. (2009). Amphetamine-Type Stimulant Use: Literature Review and Report of
Consultations (Stages 1 & 2) in the Development of a Treatment Protocol for clients of
Therapeutic Communities in Australasia. Odyssey House McGrath Foundation.
Magor-Blatch, L. & Rickwood, D. (1999). Testing a Social Cognition model for understanding the
processes in drug rehabilitation in Therapeutic Communities. ATCA Magazine.
Magor-Blatch, L. & Rickwood, D. (2008). Orientation Guide for Psychology Students. Clinical
Supervision of Postgraduate Psychology Trainees Undertaking Placements in Alcohol and
other Drug (AOD) Services. The Australian Psychological Society.
Marlatt, G.A. & Gordon, J.R. (1985). Relapse prevention: maintenance strategies in the treatment of
addictive behaviors. New York: Guilford Press.
McGregor, C., Srisurapanont, M., Jittiwutikarn, J., Laobhripatr, S., Wongtan, T., White, J.M. (2005).
The nature, time course and severity of methamphetamine withdrawal. Addiction. 100(9):
1320-9.
Miller, W.R. (1995). Motivational Enhancement Therapy with Drug Abusers. Center on Alcoholism,
Substance Abuse, and Addictions (CASAA), The University of New Mexico Albuquerque,
New Mexico.
Miller, W. R., Benefield, R.G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem
drinking: A controlled comparison of two therapist styles. Journal of Consulting and
Clinical Psychology, 61, 455-461.
Miller, W.R., C’de Baca, J., Matthews, D. B., & Wilbourne, P.L. (2001). Personal Values Card Sort.
University of New Mexico, 2001
Miller, W. R., & Rollnick, S. (Eds.) (1991). Motivational interviewing: Preparing People to Change
Addictive Behavior. The Guilford Press, New York.
Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers’ motivation for change: The Stages of
Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive
Behaviors, 10, 81-89.
Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1995). Motivational Enhancement
Therapy Manual. In Project MATCH Monograph Series, Vol. 2. Rockville, MD: National
Institute on Alcohol Abuse and Alcoholism.
National Amphetamine Type Stimulant Strategy, 2008-2011 (NATSS) (2008). Ministerial Council on
Drug Strategy.
National Institute on Drug Abuse (NIDA). (2002). Methamphetamine abuse and addiction. Research
Report Series. Department of Health and Human Services.
© Lynne E. Magor-Blatch & James A. Pitts
Page 123
Group Intervention for Amphetamine-Type Stimulants (GIATS)
National Institute on Drug Abuse (NIDA). (2003). Drug Counseling for Cocaine Addiction. Therapy
Manuals for Drug Addiction. Department of Health and Human Services.
Rosenbaum, R.L., & Horowitz, M.J. (1983). Motivation for psychotherapy: A factorial and
conceptual analysis. Psycotherapy: Theory, Research and Practice, 20, 346-354.
Rothman, R.B. & Baumann, M.H. (2003). Monoamine transporters and psychostimulant drugs.
European Journal of Pharmacology, 479, 23-40.
Smout, M.F., Longo, M., Harrison, S., Minniti, R., Wickes, W., & White, J.M. (2010). Psychosocial
treatment for methamphetamine use disorders: A preliminary randomized controlled trial
of cognitive behaviour therapy and acceptance and commitment therapy. Substance Abuse,
31, 98–107.
Substance Abuse and Mental Health Services Administration. (2006). Results from the 2005 National
Survey on Drug Use and Health: National Findings. Rockville, MD: Department of Health
and Human Services, Substance Abuse and Mental Health Services Administration, Office
of Applied Studies.
Taylor, L. (2009). Mindfulness-Based Cognitive Therapy – MBCT. 3 Day experiential intensive course
for professional development.
Wilson, K.G. & Byrd, M.R. (2004). Acceptance and Commitment Therapy for substance abuse and
dependence. In S.C.Hayes & K. Strosahl (Eds.). A practical guide to Acceptance and
Commitment Therapy (pp. 153-184). New York: Springer Press.
Wilson, K.G., Hayes, S.C., & Byrd, M.R. (2000). Exploring compatibilities between Acceptance and
Commitment Therapy and 12-Step treatment for substance abuse. Journal of RationalEmotive and Cognitive-Behavior Therapy, 18(4), 209–234.
Page 124
Lynne E. Magor-Blatch & James A. Pitts