Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
How to use the manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
1.1: Overview and aims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
1.2: Key concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Chapter 2: Recovery principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
2.1: Defining recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
2.2: The evidence base for recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
2.3: What does a recovery orientated service look like? . . . . . . . . . . . . . . . . . . . . . . . . . .16
Chapter 3: Treatment Process Model (TPM) and using maps . . . . . . . . . . . . . . . . . . . . . . . . .21
3.1: The Treatment Process Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
3.2: Introduction to mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
3.3: How do maps work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
3.4: Using the maps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Chapter 4: Recovery capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
4.1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
4.2: Measuring recovery capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Chapter 5: TPM Phase 1 – Treatment engagement and motivation . . . . . . . . . . . . . . . . . . . .35
5.1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
5.2: Enhancing client motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
5.3: Engaging client in treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Chapter 6: TPM Phase 2 – Building psychological resources and skills . . . . . . . . . . . . . . . . .55
6.1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
6.2: Self-esteem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
6.3: Self-efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62
6.4: Building a positive identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
1
Chapter 7: TPM Phase 3 – Recovery and reintegration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
7.1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
7.2: Exploring a recovery identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
7.3: Being active in recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76
7.4: Building a recovery future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
7.5: Sustaining recovery journeys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82
7.6: Family and the recovery journey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
7.7: Communication skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89
7.8: Recovery and the future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
7.9: Community recovery capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
7.10: Recovery plan reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Chapter 8: Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Appendices
1:
2:
3:
4:
5:
2
Book of Maps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
Client Evaluation of Self and Treatment (CEST) and supplementary information .155
Assessment of Recovery Capital (ARC) and supplementary information . . . . . . . .159
Recovery Group Participation Scale (RGPS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163
Linking the Treatment Process Model to
Evidence Based Psychosocial Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164
Foreword
Scotland has a serious drug and alcohol problem and in recent years, the Scottish Government has
signalled a change in the way we deal with substance misuse. The 2008 drugs strategy (Road to
Recovery) and the 2009 alcohol framework (Changing Scotland’s Relationship with Alcohol: A
Framework for Action) both call for an approach which places not only the individual but also their
community, at the centre of all care. In achieving change in any behaviour, it is vital that the
individual accept responsibility for such change. Similarly, it is essential that communities change
how they support and facilitate recovery from substance misuse.
With an emphasis on recovery, a Treatment Process Model (TPM) has been developed which brings
together evidence-based psychosocial interventions and enhanced client engagement in the
treatment process. The TPM, based around a manualised treatment programme, helps emphasise
the importance of enhancing client’s motivation for change, instilling hope in a more positive future,
and developing a range of strategies that increase feelings of self-worth and confidence. The TPM
recognises that, over time, the needs of clients will change. To be effective, therefore, treatment
approaches must adapt as they move towards a planned treatment exit. Through the use of tools
such as the Assessment of Recovery Capital (ARC) the TPM targets specific areas where support is
required, resulting in a highly tailored intervention programme.
The move toward a recovery orientated system of care is challenging. However, through the use of
the TPM, in combination with ARC and other tools, it is hoped that both service users and staff will
appreciate significant benefits.
Dr Gary Tanner
Clinical Director
Addiction Services
NHS Lanarkshire
{
...enhancing client’s motivation
for change, instilling hope in a
more positive future...
}
3
Copyright statement
© Copyright University of the West of Scotland 2010
Unless explicitly stated otherwise, all rights including those in copyright in the content of this
manual are owned by or controlled for these purposes by the University of the West of Scotland.
The right of David Best to be identified as the author of this work has been asserted by them under
the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic,
mechanical, photocopying, recording or otherwise, without permission in writing from the
copyright holder.
Except as otherwise expressly permitted under copyright law or the University of the West of
Scotland's Terms of Use, the content of this manual may not be copied, reproduced, republished,
downloaded, posted, broadcast or transmitted in any way without first obtaining the University of
the West of Scotland's written permission or that of the copyright owner.
Where documents are the responsibility of individual authors, the views contained within said
documents do not necessarily represent the views of the University of the West of Scotland.
Copyright permissions from Texas IBR/TCU for adapting and reproducing maps/materials have
been obtained.
4
Acknowledgements
This manual owes a considerable debt to two of the most significant figures in addiction research –
Dwayne Simpson, Director Emeritus of the Texas Institute of Behavioural Research at Texan
Christian University (TCU), Forth Worth and William White, author and historian, and Senior
Research Consultant at Chestnut Healthcare Systems.
This manual is in effect an extension and development of the work done within the Treatment
Effectiveness Initiative developed by the National Treatment Agency in England.
Special thanks therefore to Ed Day, Consultant Psychiatrist at the University of Birmingham, who
along with the author was responsible for the Birmingham Treatment Effectiveness Initiative (BTEI).
Node-link mapping is the central cognitive tool being used in this manual for promoting thinking
skills and decision-making strategies. It was developed by Professor Donald Dansereau (2005) for
special applications in education and counselling, and it has an extensive base of evidence for its
effectiveness. It is embedded in a rich history of pictorial and visual communication traditions
(Dansereau and Simpson, 2009).
Special thanks also to the Lanarkshire Treatment Process Model Steering Group and Cara McDowell
for their help in editing this version of the manual.
Dr David Best, West of Scotland University, April 2011
5
How to use the manual
This manual aims to support dynamic change in the treatment and care workforce within
Lanarkshire and should form the basis for delivering psycho-social evidence based interventions.
The manual is supplemented by a book of maps which you will find in Appendix 1 and these maps
will provide the basic tools for the delivery of each phase of the Treatment Process Model.
The objectives of the manual and the training programme are:
• To provide materials and tools to allow workers to develop stronger therapeutic relationships
with their clients
• To use these therapeutic relationships to deliver psycho-social evidence based interventions
in the form of node-link maps
• To enable workers to support clients in their recovery journeys and to develop the support
system and recovery communities that are needed to support recovery-orientated treatment
interventions.
This manual is designed to be used as a reference guide. However, please note that the maps
contained within the manual are a means of supplementing and complementing the recovery
support skills and therapeutic input of the key worker, not a replacement for these. We hope these
will provide the foundations for creative and dynamic work by staff which will support the recovery
ethos in Lanarkshire.
{
6
...aims to support dynamic change
in the treatment and care
workforce within Lanarkshire...
}
Chapter 1
Introduction
1.1 Overview and aims
The growth of the Recovery Movement in the UK, building on strong foundations in mutual aid and
local recovery communities over many years, has provided the addictions field with a renewed sense
of hope and increased beliefs and aspirations for our clients. This new wave of optimism is captured
in the Scottish alcohol and drug strategies - in which recovery is made central to the philosophy and
aims of all treatment and care systems. Much of what is presented within a recovery model is not
new but is an attempt to build on the successes we know from our own field and to learn from
other areas – including the recovery movement in mental health and the significant work done in
North America.
In 2010 the Alcohol & Drug Partnership (ADP) set out their vision to develop a recovery oriented
system of care in Lanarkshire within their Recovery Strategy (2010 – 2014). The central pillars of
this system of care include:
• providing all drug and alcohol users with hope of recovery and the skills and support to help
them plan for this journey
• creating a sense of dynamism that does not accept that clients get ‘stuck’ or that some
clients are too chaotic to move forward
• generating communities of recovery where peers are active participants in recovery
journeys and who can act as icons of recovery for those starting recovery journeys, while
the role of the professional diminishes over time
• ensuring that all clients in recovery – maintained or abstinent – have clear goals of
participation in their local communities and families and through doing so challenge
stereotypes and stigma
• acknowledging that recovery is seen as a complex and multi-faceted process requiring
partnerships that are flexible and fluid and that include not only those in recovery but also
their families
• providing a variety of routes to recovery to enable clients to own their journeys and have
real choices about whether treatment is needed and if so what that treatment means.
As outlined within the strategy there is no assumption that having more people in treatment or
having people in treatment for longer are positive outcomes. Ultimately the question will be how
many of those who seek help receive meaningful choices in a timely way. The purpose of this
manual is to assist staff to help clients achieve their goals around the psychological aspects of
recovery (wellbeing, quality of life, coping, self-esteem and self-efficacy) and social functioning
(including relationships, family engagement, training, employment and domestic arrangements).
7
1.2 Key concepts
Treatment Process Model
This manual is essentially designed to enable key workers to support clients through three
sequential phases of the recovery process in treatment, as defined by the Treatment Process Model
(TPM). The TPM model is based on three distinctive phases of treatment:
Phase 1 - Treatment engagement and motivation
This model suggests that there are stages in recovery where treatment is part of the recovery
process. The creation of a strong therapeutic relationship and a client motivated to change
are the two key elements of treatment that can offer a difference.
Phase 2 - Building psychological resources and skills
This enables a process of psychological growth involving the emergence of a positive identity,
increased self-esteem and self-efficacy, and that these manifest themselves in improved selfregulation (resilience skills and preventing relapse) and self-management (which includes basic life
skills and coping with the demands of sober living).
Phase 3 - Recovery and reintegration
The growth of personal resources enables and is in turn supported by the development of longterm recovery capital – primarily based on social supports and the active engagement with the
local community.
The therapeutic relationship between key worker and client remains the primary building block
of what treatment has to offer. It should provide the ‘spark’ of hope and the belief that not only
is recovery possible but that treatment will provide that goal and direction.
Recovery capital
Throughout this manual, there are references to building recovery capital. This is a key outcome of
the Treatment Process Model that will be implemented in Lanarkshire alcohol and drug services.
Recovery capital is the quantity and quality of internal and external resources that can be
mobilised to initiate and sustain the resolution of severe alcohol and other drug problems
(Granfield and Cloud, 1999).
Within the wider definition of recovery capital, there are three main concepts that contribute to the
building of overall ‘recovery capital’:
• Personal recovery capital - key strengths and resources that clients have
• Social and family recovery capital - helpful people they are engaged with that can support them
• Community recovery capital – community resources and supports including treatment
services, housing etc.
Thus, recovery capital will change over time and is amenable to measurement as a mechanism for
assessing appropriate interventions at different phases in the Treatment Process Model. This will be
discussed in more detail in Chapter 4.
8
The Assessment of Recovery Capital Star (ARCS) - Measuring recovery
Recovery group
capital
Phase 3
5
4
3
Treatment
engagement
2
5
4
3
2
1
2
3
4
5
2
1
1
Phase 1
Treatment
motivation
1
3
4
5
Social
recovery
capital
1
2
3
4
5
Personal
recovery
capital
Phase 2
The ARCS is an essential tool for key workers in Lanarkshire’s alcohol and drug services. This tool is
used to
• Indicate where the client is in their recovery journey
• Map out the strengths they have and what domains those strengths are in
• Direct the key worker to which areas may be the most appropriate for focusing their efforts
• Linking to the maps in this manual to suggest specific areas for mapping and discussion
• Indicating whether the focus should be on psychological interventions or on linkage to
recovery groups and activities in the community.
The ARCS is a visual depiction of assessment scores, created by key workers and clients undertaking
a series of assessments throughout the three phases of the Treatment Process Model. Further
information about these assessment tools and how they create the ARCS is provided in Chapter 4.
Maps
Key workers will be supported to implement this new Treatment Process Model by a series of tools
called maps (Appendix 1). These can be used by workers to improve communication and support
the growth of the therapeutic relationship with their clients and psychosocial change.
The maps provided are modelled on a set of techniques call Node-Link Maps. Research across a
range of disciplines has shown that visual displays have a number of significant advantages over
standard language and they can enhance communications between key workers and clients. In turn,
this improves the therapeutic relationship and in a more empowering way, actively engages the client
in the treatment process. It does this by helping make ideas clear and simple, ensuring both parties
are talking about the same thing and providing a record of the discussion that worker and client can
return to at the next meeting. More information about maps can be found in Chapter 3 of this
manual.
9
Recovery champions
The Lanarkshire ADP’s Recovery Strategy (2010 – 2014) outlines our commitment to establishing a
network of community, therapeutic and strategic champions who are visible across the whole
treatment system, within all organisations and in each locality in Lanarkshire.
Recovery champions are the community component of enabling effective recovery journeys. Using
the Asset-Based Community Development model, the assumption is not that champions have to be
‘created’ but that they have to be identified and supported through clear guidance and leadership.
Strategic recovery champions: are professionals who have the role of commissioners or
strategic managers within key services in a locality who will be required to have the energy and
vision to challenge cultural, funding and pragmatic barriers to implementing recovery practices.
The strategic champions are represented within the Lanarkshire Alcohol and Drug Partnership,
the Addictions Partnership Board in North Lanarkshire and the Joint Services Management
Group in South Lanarkshire.
Therapeutic recovery champions: are the frontline key workers who see the merit in the
recovery movement, perceive themselves to have a key role to play in it and who will drive
forward the change to a recovery model in the services they work in.
Community recovery champions: will consist of a range of people in recovery, but will not be
restricted to them. They are the human resources in the local community and so will also include
the families of those in recovery and active addiction, the forceful drivers of local community
development and all of those local community stakeholders who can be engaged in recovery
transformations of local communities. However, the people in recovery themselves have a crucial
role to play as the ‘social learning role models’ of recovery – the living proof that recovery does
happen and that it has happened to the peers of people in active addiction. But this group needs
to be supplemented by a wider network of community supports and systems that will maximise
the opportunities for individual recovery.
These individuals will be key to the successful integration of service users, community based
support structures (e.g. mutual aid groups), existing health and social care providers and third sector
organisations. In essence, they will be the nucleus of a network of interconnected cells, developing
multiple connections across and within each locality in Lanarkshire.
10
The role of therapeutic recovery champions
Therapeutic recovery champions are aiming to help people discover their own solutions, and to offer
what support they can to allow people in recovery to learn and grow for themselves, rather than to
provide solutions for addiction problems. The key role for the key worker or therapeutic agent in
promoting a recovery model is to offer:
• Empowerment
• Choice
• Hope
• Respect
• Guidance
The therapeutic recovery champion will recognise that the treatment service is not the locale in
which recovery will take place and that partnerships with the wider community are essential within a
recovery focussed service. The therapeutic recovery champion will therefore:
• act as a bridge to key resources in the community- not only mutual aid groups but key
associations and institutions in the community (fishing groups, neighbourhood watch
schemes, churches, libraries)– and that they will also be prepared to get involved in assertive
linkage with these groups (Dennis et al, 2009).
• enable and support change among their colleagues and in the service by challenging
professional attitudes and barriers and acting as the visible and forthright champion of
strengths-based working and recovery thinking as the means of delivering support to clients.
• deliver a strengths-based approach to the face-to-face work done with clients by utilising
strengths based assessment and recovery planning processes, focusing on building recovery
capital and acting as a guide and a bridge to enabling client recovery.
Note: We have used the word ‘drug’ throughout this manual.
This means any drug which has caused problems in the past, including alcohol.
{
...a renewed sense of hope
and increased beliefs and
aspirations for our clients...
}
11
Chapter 2
Recovery principles
2.1 Defining recovery
The UK Drug Policy Commission convened a meeting of senior UK practitioners and academics,
people in recovery and family members to develop a UK ‘vision’ of recovery. Recovery was
characterised as a process of: “voluntarily sustained control over substance use which maximises
health and wellbeing and participation in the rights, roles and responsibilities of society” (UK Drug
Policy Commission, 2008, p.6). The report emphasises the range of routes to recovery and also
suggests that this includes “medically maintained abstinence” (UKDPC, 2008, p.6). In The Road to
Recovery (Scottish Government, 2008), recovery is defined as: “a process through which an
individual is enabled to move from their problem drug use, towards a drug-free lifestyle as an active
and contributing member of society.” The Report went on to declare that “recovery is most
effective when service users’ needs and aspirations are placed at the centre of their care and
treatment….an aspirational and person-centred process” (Scottish Government, 2008, p.23).
In the United States, the Betty Ford Institute Consensus Panel (2007, p.222) defined recovery as
“a voluntarily maintained lifestyle characterised by sobriety, personal health and citizenship.”
The Consensus Panel further detailed the meaning of sobriety by explicitly stating that “formerly
opioid-dependent individuals who take naltrexone, buprenorphine, or methadone as prescribed and
are abstinent from alcohol and all other non-prescribed drugs would meet this definition of
sobriety” (p.224). The Panel further differentiated the stages of recovery as ‘early sobriety’ (the
first year), ‘sustained sobriety’ (between 1 and 5 years), and ‘stable sobriety’ (more than five years).
Through this collective definitional work to date, recovery from a substance use disorder has been
characterised by three core dimensions of change (White, 2007):
1. remission of the substance use disorder
2. enhancement in global health (physical, emotional, relational, occupational and spiritual)
3. positive community inclusion
{
Recovery is most effective when service
users needs and aspirations are placed at
the centre of their care and treatment.
}
13
2.2 The evidence for recovery
There is a history of research that shows that alcohol and drug treatment is effective in supporting
change and promoting recovery from substance use problems. These date back to the DARP study
in the US (Simpson and Sells, 1990) which investigated four different treatment modalities and
involved follow-up windows of up to 12 years, showing that among those patients who had been
daily users of opioids before treatment, more than half (53%) reported no daily opioid use at one
year. Opioid use continued to decline over time until year 6, when it stabilised at 40% for 'any' use
and 25% for 'daily' use. At some point during the 12 years following treatment, three quarters of the
sample had relapsed to daily opioid use, but at the year 12 interview, nearly two thirds (63%) had
not used opioids on a daily basis for a period of at least 3 years. Subsequent large-scale US followup studies (TOPS, Hubbard et al, 1989; DATOS, Flynn et al, 1997) continued to show positive gains
across treatment modalities, that were subsequently replicated in an English (NTORS, Gossop et al,
2005) and Scottish (DORIS, McKeganey et al, 2003) treatment settings.
According to William White, recovery is the rule rather than the exception: most (50% or more)
people with significant alcohol or other drug problems (meeting diagnostic criteria for a substance
use disorder) will eventually resolve those problems (See White, 2008a for a review).
In the review of recovery evidence by the Centre for Substance Abuse Treatment (2009), the
overall estimate of the proportion of those with a lifetime substance dependence who will
eventually achieve recovery is 58%.
The prognosis for long-term recovery varies markedly by degree of problem severity and by
personal, family and community recovery capital (White, 2009b; Granfield & Cloud, 1999, 2001).
There is a growing body of scientific literature positing stage theories of addiction recovery (DeLeon,
1996, 2007; Frykholm, 1985; Klingemann, 1991; Prochaska, DiClimente & Norcross, 1992; Shaffer &
Jones, 1989; Waldorf, 1983; Waldorf, Reinarman & Murphy, 1991). When research on recovery
stages is viewed as a whole, four broad stages of recovery are evident:
1) Pre-recovery problem identification and internal/external resource mobilization
(destabilisation of addiction and recovery priming)
2) Recovery initiation and stabilization
3) Recovery maintenance
4) Enhancements in quality of personal/family life in long-term recovery and across the
personal/family life cycle.
The point of recovery stability/durability (point at which the risk for future lifetime relapse drops
below 15%) is typically 4-5 years of sustained recovery for alcohol dependence, but potentially
longer for other drug dependencies. White & Kurtz (2006) have estimated that the typical time from
last use of heroin to stable recovery is around 5-7 years.
14
Recovery careers—their initiation and durability—are influenced by the interaction of problem
severity/complexity and personal recovery capital. Much of the assessment and measurement work
of Chapter 4 will use recovery capital as a way of assessing what is appropriate for the client in
treatment. Internal assets can be thought of as personal recovery capital and external assets can be
thought of in terms of family and community recovery capital (White & Cloud 2008). Thus, recovery
capital will change over time and is amenable to measurement as a mechanism for assessing
appropriate interventions.
Evidence within the UK
The primary source of this work, at least from a drugs’ perspective, comes from 70 semi-structured
interviews conducted by McIntosh and McKeganey and published in papers in 2000 and 2001.
Among the key desistance factors identified were developing new activities and relationships and
developing a commitment towards new and changed lifestyles, at least in part by developing an
identity as a non-addict. The authors identified two main mechanisms by which former users
avoided relapse – “(1) the avoidance of their former drug-using network and friends and (2)
the development of a set of non-drug-related activities and relationships” (McIntosh and
McKeganey, 2000).
{
...developing new activities and relationships
and developing a commitment towards new
and changed lifestyles...
}
In 2008, Best and colleagues published the findings of a survey of 107 former problematic heroin
users who have achieved long-term abstinence about their experiences of achieving and sustaining
abstinence. The cohort was recruited opportunistically from three sources, drawing heavily on
former clients working in the addictions field. On average, the group had heroin careers lasting for
just under 10 years, punctuated by an average of 2.6 treatment episodes and 3.1 periods of
abstinence - the most commonly expressed reason for finally achieving abstinence was ‘tired of the
lifestyle’ followed by reasons relating to psychological health. In contrast, when asked to explain how
abstinence was sustained, clients quoted both social network factors (moving away from drug using
friends and support from non-using friends) and practical factors (accommodation and
employment) as well as religious or spiritual factors. More recent work on the Glasgow Recovery
Study (Best et al, submitted), has reviewed recovery experiences of 205 former drinkers and drug
users and found that two factors strongly predicted the quality of life of those in recovery:
1. The amount of time spent with other non-users also in recovery
2. The amount of time the person spent engaged in meaningful activities (childcare,
volunteering including engaging in recovery group activity, education and training, and
part-time and full-time working)
15
While the evidence base around addiction recovery in the UK is limited, there is a much more
vibrant evidence base around the mental health recovery movement. For the Scottish Recovery
Network, Brown and Kandirikirira (2007) used a recovery narratives model as part of a methodology
that acknowledges the uniqueness of the lived experience of people in recovery, and identified a
range of both internal and external elements involved in recovery process. The internal elements
included self-belief, belief that recovery is possible, meaningful activities in life, positive relationships,
an understanding of the illness and active engagement in recovery strategies. The external factors
included supportive friends and family, being told recovery is possible, being valued, having
responsive formal support, living and being valued in the community and having life choices
accepted. Defining a clear sense of self was seen as being as important as managing or overcoming
symptoms. Also in the Scottish context, Shinkel and Dorrer (2007) have identified some key areas of
recovery oriented culture change that have potential application in the addictions field, relating to
key workers’ attitudes and beliefs about the recovery prospects of their clients:
• Belief in and understanding of recovery
• Respectful relationships
• Focus on strength and possibilities
• Care and support directed by the service user
• Participation in recovery of significant others
• Challenging stigma, discrimination and social stigma
• Provision of holistic services and supports
• Community involvement
2.3 What does a recovery orientated service look like?
The purpose of a recovery focus is to help individuals achieve improvements in their quality of life
and wellbeing with an assumption built in that this will not only be a personal process of
development, but it has implications for services and for treatment systems.
The Centre for Substance Abuse Treatment (CSAT, 2009) has outlined 17 recovery-oriented
principles for a recovery system that are outlined below:
• Person-centred
• Inclusive of family and other ally involvement
• Individualised and comprehensive services across the lifespan
• Services anchored in the community
• Continuity of care
• Partnership-consultant relationships
• Strengths-based
• Culturally responsive
• Responsiveness to personal belief systems
16
• Commitment to peer recovery support services
• Inclusion of the voices and the experiences of recovering individuals and their families
• Integrated services
• System-wide education and training
• Ongoing monitoring and outreach
• Outcomes driven
• Research based
• Adequately and flexibly financed
The switch to a recovery model has been largely driven by the growth of a grass roots addiction
recovery advocacy movement in the US and UK. Among the key objectives of this model is an
approach that is 1) calling for a reconnection of addiction treatment to the more enduring process
of addiction recovery, 2) advocating a renewal of the relationship between addiction treatment
institutions and grassroots recovery communities, and 3) extolling the power of community in the
long-term recovery process (Elise, 1999; Morgan, 1995; White, 2002, 2009b).
Recovery models and links to acute treatment
A fundamental part of initiating a recovery model is the switch from a ‘pathology’ model to a
strengths model, and is about identifying what key resources the client has to build on and where
the gaps are that need to be addressed. The theoretical part of this process is the assumption that it
is very difficult for clients to make significant progress in their recovery journeys unless two basic
conditions are met:
1. The person has a place to live that is free from threat and provides basic warmth and safety
2. That they are sufficiently free of physical and psychological health symptoms that they can
start to plan for the future
{
...help individuals achieve
improvements in their
quality of life and wellbeing...
}
17
While at one level, the aim is to work towards eliminating threats and maximising strengths, there is
not an assumption that recovery requires all of the threats to be eliminated. The underlying
rationale is based on the idea that recovery is about the development of strengths that allow
intractable problems – mental health, addiction, etc – to be managed and not to interfere with
quality of life. The start of the recovery journey is likely to be predicated on fundamental changes
that allow initiation of recovery. White (1990) has also argued that there is a ‘physical zone’ in
recovery that includes:
• ensuring recovery-enhancing physical shelter
• establishing daily rituals of self-care, cleanliness and dental hygiene
• reducing or removing the threat of physical violence
• resolving life-threatening or sobriety-threatening medical problems
• reversing drug-induced retardation
• achieving a normalised sleep pattern
• identifying and treating concurrent mental health problems
• overcoming drug-related anhedonia
• managing other toxic habits around caffeine, sugar and tobacco
• initiating drug-free sexual functioning
Many of these elements of the ‘physical zone of recovery’ will be essential prerequisites for initiating
the key psychological, spiritual, social and lifestyle changes that are required. The model presented
here is essentially about working with clients who have achieved that basic level of functioning.
What does this mean in practice for services and service staff?
“A common purpose: Recovery in future mental health services”, a Joint Position Paper, by the Care
Services Improvement Partnership (CSIP), the Royal College of Psychiatrists and the Social Care
Institute for Excellence (SCIE) suggested that “in order to support personal recovery, services need
to move beyond the current preoccupations with risk avoidance and a narrow interpretation of
evidence-based approaches towards working with constructive and creative risk-taking and what is
personally meaningful to the individual and their family” (Joint Position Paper, 2008, p6).
The recovery movement is about some key principles:
1. Empowerment of the service user
2. Involvement of their family, and developing community and peer supports
3. Dynamism that helps clients move forwards with their lives and that the focus is not all about
the substance
This means that services have to be open and adaptable to what is available in the communities
they are based in. Repper and Perkins (2003) have advocated for mental health: “...teams should
develop central, indexed stores of information concerning community resources, housing, benefits,
work projects and advocacy. All staff should have basic knowledge of what these stores contain”
(Repper and Perkins, 2003, p190).
18
The key worker therefore has to be clear about the individual needs and dignity of the client and to
see their professional role as supportive and empowering. This is consistent with the findings of
Kirkpatrick et al (2001) that professionals who project messages of hope are a greater help to their
clients, and that clients confer extra value on professionals who are seen to go the extra mile and to
act in the role of a critical friend (Berg and Kristiansen, 2004). This finding supplements the key
finding by Norcross et al (2002) that the relationship between client and therapist accounts for the
largest amount of variance that is not accounted for by pre-admission client characteristics. In
“Pathways from the culture of addiction to the culture of recovery” (White, 1990), William White lays
out six key tasks for the addiction professional in supporting recovery:
1. Create consciousness of excessive behaviour in the treatment environment
2. Teach that excess is a developmental stage in recovery
3. Encourage daily rituals for self-assessment and focusing
4. Teach sobriety-based coping skills
5. Facilitate the establishment of a sobriety-based social network
6. Periodic assessment of the client in aftercare for risk of relapse
For the service, the key is to be linked into the community it serves – that means effective links to:
• 12-step groups
• SMART recovery groups
• Other mutual aid groups
• Local community services and supports
• Aftercare groups
• Housing services
• Employment and training agencies
• Family support services
The effectiveness of recovery journeys will happen in the community and will be based in part on
the successful reintegration of clients into their local communities. Services have to act as part of
those local communities – with their doors open to the above groups and their staff aware of and
engaged in local activities in the community (see Chapter 1.2 Key Concepts, Recovery Champions).
19
Chapter 3
The Treatment Process Model & using maps
3.1 The Treatment Process Model (TPM)
At the core of the notion of a treatment journey is the Treatment Process Model (TPM) developed
by Dwayne Simpson who generated much of the research foundations for much of this manual.
This research is based on three different types of studies about what works within the addictions
field:1. The treatment outcome and evaluation studies conducted between 1969 and 1989 showing
that treatment generally leads to improvements in client outcomes
2. Studies on conceptual model and treatment process between 1989 and 2009 focusing on the
relationships between client attributes, the treatment context and treatment processes in
predicting outcomes and
3. Current work on the strategic implementation of what works under the rubric of “technology
transfer”.
The culmination of this evidence base provides a model for treatment delivery. In essence this
suggests three distinct phases of treatment:• Treatment engagement and motivation
• Building psychological resources and skills
• Recovery and Reintegration
This manual is essentially designed to enable workers to support clients through these sequential
phases of the recovery process in treatment. Figure 1 overleaf shows the basic formulation of that
process in which workers map the interventions they deliver against the stage the client has reached
in their treatment journey. Thus, much of the work in the early engagement phase has the objective
of retaining and motivating the client and is predicated on the development of a therapeutic
relationship between the key worker and client. Techniques that can be appropriate here include
motivational enhancement work which is geared around improving the client’s motivation to change
and their motivation to engage actively in the treatment process.
21
Figure 1: The Treatment Process Model
Motivation
Early
engagement
Early
recovery
Risk &
severity
Program
participation
Change:
Behavioural
Treatment
readiness
Therapeutic
relationship
Change:
Psychosocial
Change in
treatment
Post
treatment
Wellbeing
Increased
personal
capital
Families
Communities
Adapted from Simpson (2004) and Simpson and Joe (2004).
Phase 1: Treatment engagement & motivation
This model suggest that there are stages in recovery where treatment is part of the recovery process
and that where treatment can offer a difference it does so on the basis of a strong therapeutic
relationship and a client who is motivated to change.
Phase 2: Building psychological resources & skills
This enables a process of psychological growth involving the emergence of a positive identity,
increased self-esteem and self-efficacy, and that these manifest themselves in improved selfregulation (resilience skills and preventing relapse) and self-management (which includes basic life
skills and coping with the demands of sober living).
Phase 3: Recovery & reintegration
The growth of personal resources enables and is in turn supported by the development of long-term
recovery capital – primarily based on social supports and the active engagement with the local
community.
In the first UK implementation of this work, the primary focus was on the early engagement phase
with two of the manuals developed specifically targeting the engagement of clients by providing
supports and techniques for workers to improve motivation and to encourage more participative
care planning (these will be discussed in more detail within Chapter 5). However the primary focus
of this manual will be on the last two phases – where clients are looking to move forward in their
recovery journey – and so the focus is in part about building their recovery capital and in part about
linking them to the support groups that will enable and facilitate their engagement in community
and family life (discussed in more detail within Chapters 6 and 7).
The therapeutic relationship remains the primary building block of what treatment has to offer –
in other words, it is the relationship with the service and particularly with the keyworker that
should provide the spark of hope and the belief that not only is recovery possible but that
treatment will provide that goal and direction. For this reason, the first phase of the model and
the core principle underlying effective recovery treatment is “therapeutic capital” – the recovery
strength that flows from the treatment process and the resulting motivation to change and to
strive for positive personal recovery outcomes.
22
3.2 Introduction to mapping
The basic mechanism that the model is built on is designed to improve communication and to
support the growth of the therapeutic relationship. Underlying this approach is a set of techniques
that are called “node link maps” and they are the building blocks of this manual for the work that
key workers will do with their clients. As Dansereau and Simpson (2009) have argued, research
across a range of disciplines shows that visual displays have a number of significant advantages over
standard language, and that they can enhance communications between counsellors and clients.
A summary of some of the main advantages for the use of visualisation techniques is given in
Figure 2 below:
Figure 2: The benefits of maps
Provides a
workspace for
exploring problems
Trains clearer and
more systematic
thinking
Creates a memory
aid for clients
and workers
Improves the
therapeutic alliance
The benefits
of maps
Provides a method
for getting unstuck
Focuses attention on
the topic at hand
Provides an easy
reference to earlier
discussions
A useful structure
for clinical supervision
Dansereau and Simpson have summarised research evidence that shows an advantage for pictorial
representation over traditional language in the communication of complexity and emotion and what
is depicted in Figure 2 are the main benefits that have been demonstrated from the research base
about visualisation techniques. In essence, the node-link mapping approach is a way of distilling
that into a model for supporting workers to share communications more effectively, to allow for
exploration of new concepts and for clarity of purpose and goals. However, what the evidence base
clearly articulates is that this is a mechanism for improving the therapeutic relationship by
communicating more effectively and in a more empowering way that actively engages the client in
the treatment process.
23
The basic principle of this model is about attempting to make ideas clear and simple, ensuring that
both parties are talking about the same thing and that both client and key worker have a record of
the discussion that they can come back to when they next meet. Maps will vary by the task being
addressed in the mapping process but the basic principles of mapping remain the same and are
highlighted in Figure 3 below:
Figure 3: Node-link maps
A NODE, which is just an idea captured in a box, circle, or other shape
For example:
Blockbuster
movie
LINKS (named or not) which show the relationship between nodes
For Example:
Blockbuster
movie
“An Example of a
Blockbuster movie
is Titanic”
Titanic
Nodes and links are the basic building blocks used in the maps in this manual. There are a number
of benefits to using maps:
• consistency and effectiveness of communication
• create an audit trail for clients, key workers and managers, showing progress
• highlights areas for future exploration with clients
• flexibility - maps can be used in many ways
However, the bottom line is that they work. The many studies done by Simpson and colleagues in
the States and more recently in the UK and Italy have shown that the use of mapping:
• leads to greater client motivation for drug treatment
• improves the worker-client therapeutic relationship, and clients’ perceptions of the quality of
therapeutic sessions
• enhances client self-perceptions
• reduces the number of missed client appointments
• reduces the number of positive urine tests
Furthermore, in the UK, work completed jointly with the National Treatment Agency (NTA) in the
English Midlands and North-West (Simpson et al, 2009; Best et al, 2009) illustrated that there were
also indications that staff generally valued the approach and found that it led to better client
engagement in services as well as to greater key worker engagement and satisfaction.
24
3.3 How do maps work?
As highlighted below in Figure 4, there are basically three different types of maps that are used as
the building blocks for the manuals and these are:
• Knowledge maps
• Guide maps
• Free maps
Figure 4: Types of node link maps
Node-link
mapping
T
T
T
Knowledge maps
C
C
Worker
produced
C
Convey
information
Legend:
Free mapping
Guide maps
C
C
C
T Type
C
Framework
provided by
worker
Jointly
produced
Structured
Over 50 publications
have shown its
effectiveness
C
Spontaneous
Structured/Free
C
C
Represent & explore
personal issues
Represent & explore
personal issues
C Characteristic
25
Essentially, the maps offer different levels of structure. At the most basic level, an information map
is not interactive but provides information to clients about particular topics. These would be handed
out to clients to explain a particular issue. Thus, Figure 5 provides a basic map about HIV that is
meant to be given to clients to improve their understanding of the basic concept. These can be
useful for explaining complex topics but are primarily instructive and lack the interactive and shared
quality that make maps useful as a therapeutic tool.
Figure 5: An information map
I
H
R
V
R
R
ImmunoDeficiency
Human
C
Virus
C
C
Smallest
living
microbe (germ)
Survives by
invading cells and
destroying
them
A major
problem
with the Immune
System that
fights
disease
People Only
Can not be
spread by animals,
plants, or
insects
HIV is a human virus that invades and destroys the cells of the immune system.
I
A
R
Acquired
C
Can be acquired.
In other words,
it can be spread
D
R
Immune
C
Refers to the
immune system.
White blood cells
that fight disease
S
R
Deficiency
R
Syndrome
C
Not working.
Deficient.
Unable to fight
germs
C
A group of
illnesses
or symptoms
related to a
specific cause
(HIV)
AIDS is the late stage of HIV infection, resulting in illnesses and cancers
the body can no longer fight off.
26
The second kind of map is the guide map (also known as structured maps) – basically this is a ‘fill
in the blanks’ graphic tool that can be used to facilitate self-exploration, planning, decision-making
and problem solving. In the Birmingham Treatment Effectiveness Initiative (BTEI), these were widely
used in the care planning process and in reviews but were also used as part of the initial assessment
to help key workers get to know clients. Thus, Figure 6 below is basically a structured form that the
client and key worker fill in jointly so that the client can describe themselves and the key worker can
start to get a sense of them as a person. This kind of basic map can then be used at review points
to explore change and to examine what is different about the client.
Figure 6: A guide map
Health and physical
Problem solving
/Coping
Social relationships
What are
your strengths?
Emotions /
temperament
Values and beliefs
Work and skills
It is important that the guide maps are completed as a shared process therefore the seating
arrangement should allow the client not only to see what is being done but also to take the pen and
to ‘own’ the process.
27
The guide map is the basic tool of the mapping process and provides a record that each party
should be given a copy of at the end of the session. The reason for this is to give the client a
sense of ownership of the session, as a reminder of what has been done and of what needs to
be done. Individual maps can be reviewed as part of the process of mapping the recovery
journey or repeated, but the key thing is that they are living documents to be viewed as
milestones in the therapeutic relationship and in the recovery journey.
Guide maps can be used flexibly – in other words, the structure and contents can be changed to suit
the particulars of the working context and the needs of that client. This flexibility is most obvious
when free maps are used.
The third kind of map is the free map as shown in Figure 7 below. These are produced from scratch
by clients and key workers and can be used as a note-taking technique or as a vehicle for expressing
and organising personal knowledge. This may be a good way of getting to know someone and
beginning the process of understanding how the client sees themselves and how they organise their
thinking.
Figure 7: A free map
In our experience of delivering training around mapping, it is free mapping that key workers
generally find the most useful and enjoyable but they will first need to reach a point where they are
comfortable with using the technique and working with clients.
28
3.4 Using the maps
Mapping is a technique not a therapeutic intervention in its own right and one of the key aims of
the treatment process model is to reconcile this with the skills and specialities that key workers
already possess. However, due to their flexible nature, key workers will be able to use maps to suit
their own working practices and the needs of their clients. Some maps will be used only once but
several can be repeated or updated. They are a resource to use with clients to improve the clarity of
the communication and to help guide the client through the process of treatment and recovery.
In one setting, this became so popular, that the first activity that took place in an initial assessment
meeting was for key workers to sit with a blank sheet of paper and ask clients to map out their lives
with them. This would both develop a personal link before starting on the structured assessment
and would be a way for the key worker to get to know a bit about the client and what they wanted
and needed – essentials for starting a recovery journey.
The manual will also provide ‘signposts’ for key workers about which sets of maps to use with
particular clients – this will be linked to how the client scores on the recovery capital assessment
measure. The basic Treatment Process Model outlined previously in this chapter forms the basis of
how specific types of maps link to where the client is in terms of their recovery journey and their
engagement with treatment. Within the Treatment Process Model, the treatment process is both a
catalyst for recovery change and a component part of the recovery process.
As with all of the mapping exercises in this manual, these are not one-off exercises that are
forgotten, they are parts of a portfolio of recovery and both key worker and client should keep a
copy of all of these as ways of charting the stages of the recovery journey and reflecting on their
role in enabling and sustaining overall recovery, through setbacks and problems.
Further information about maps and when they are best used can be found in chapters five, six and
seven of this manual. Information is also available on the Lanarkshire Alcohol and Drug Partnership
website http://www.lanarkshireadp.org/. The set of maps referred to in this manual are contained
within Appendix 1 but you may also wish to visit the Texan Christian University (TCU) website
(www.ibr.tcu.edu) to download copies of the following manuals which use the principles of link node
mapping outlined within the chapters that follow:• Getting Motivated to Change
• Mapping Your Treatment Plan: A Collaborative Approach
• Preparation for Change: the Tower of Strength and the Weekly Planner
• Understanding and Reducing Angry Feelings
• Ideas for Better Communication
• Building a Social Network
• Straight Ahead: Transition Skills for Recovery
29
Chapter 4
Recovery capital
4.1 Introduction
Recovery capital is described as the quantity and quality of internal and external resources that can
be mobilised to initiate and sustain the resolution of severe alcohol and other drug problems
(Granfield & Cloud 1999). Internal assets can be thought of as personal recovery capital and
external assets can be thought of in terms of family and community recovery capital (White & Cloud
2008). Although the worker/client relationship can be very important, Repper and Perkins (2003,
p54) have argued that “professionals do not hold the key to recovery: relationships with others –
friends, families, neighbours, colleagues, - are more central.” This manual therefore encourages key
workers to focus on the positive relationships and meaningful activities that are often at the heart of
successful recovery journeys. White and Cloud (2008) suggest that the growth of recovery capital
can signal a “turning point” in addiction careers in that, where clients have a growth in recovery
capital, there can be a dramatic change in their opportunities for life change and sustainable
recovery.
• A person with a moderate alcohol or drug problem severity but high recovery capital
might well achieve and sustain recovery on their own, through screening and brief
professional intervention, or though support form a non-specialised service.
• A person with high problem severity and complexity but exceptionally high recovery
capital might be appropriate for outpatient detoxification and outpatient treatment despite a
level of problem severity that, viewed in isolation, may justify inpatient rehabilitation.
• In contrast, a person with low problem severity but high risk factors paired with
extremely low recovery capital might be in need of residential treatment, ongoing
professional support and prolonged peer-based recovery support.
• Finally, a person with high problem severity and low recovery capital will likely require
services of high intensity, broad scope (e.g. outreach, assertive case management), and long
duration (White & Cloud 2008).
One of the key objectives of the transition to a recovery model, and one of the main objectives
of recovery interventions, is to focus on enabling clients to build their recovery capital and to
develop the resources that will not only enable them to become alcohol or drug free but also to
develop and grow.
Recovery capital will change over time and is amenable to measurement as a mechanism for
assessing appropriate interventions. In order to create recovery profiles that will allow the worker to
identify the most appropriate intervention to offer, the following needs to be considered:
• The individuals motivation to change and to engage with recovery support
• The strengths drawn from the therapeutic alliance
•
The individuals strengths drawn from engagement in recovery groups
31
4.2 Measuring recovery capital
This manual describes the use of three assessment tools which when used together, produce the
Assessment of Recovery Capital Star (ARCS). The ARCS provides a visual depiction of
assessment scores throughout the phases of the Treatment Process Model and is highlighted
in Figure 8 below. The purpose of the ARCS is:
• To indicate where the client is in their recovery journey
• To map out the client’s strengths and highlight what domains those strengths are in
• To direct the worker to which areas may be the most appropriate for focusing their efforts
• To link to the maps in this manual to suggest specific areas for mapping and discussion
• To indicate whether the focus should be on motivation and engagement (TPM Phase 1),
building psychological resources and skills (TPM Phase 2) or on linkage to recovery groups
and activities in the community (TPM Phase 3).
Figure 8: The stage process of the Assessment of Recovery Capital Star (ARCS)
Recovery group
capital
Phase 3
5
4
3
Treatment
engagement
2
5
4
3
2
1
2
3
4
5
2
1
1
Phase 1
Treatment
motivation
1
3
4
5
Social
recovery
capital
1
2
3
4
5
Personal
recovery
capital
Phase 2
Listed below are the three assessment tools which are used to produce the Assessment of Recovery
Capital Star (ARCS) with information regarding their use and relationship to the Treatment Process
Model.
Client Evaluation of Self and Treatment (CEST, Joe et al 2002): This tool was the key instrument
used within the early recovery work conducted at the Texan Christian University work and measures
four domains: motivation to change, psychological functioning, social functioning and treatment
engagement. Within this manual and the ARCS, the motivation and participation subscales of the
CEST are used to identify scores on treatment engagement and motivation in order to determine
whether the treatment sessions and activities should focus on Phase 1 of the Treatment Process
Model. The techniques to support this are laid out in Chapter 5. Please refer to Appendix 2 for a full
copy of the CEST and supplementary information.
32
Assessment of Recovery Capital (ARC): This tool provides a self reported indicator of the basic
dimensions of personal and social recovery capital using 10 domains which include substance use
and sobriety, psychological health, and social support amongst others. Developing this profile for
recovery will represent Phase 2 of the Treatment Process Model (TPM) and Chapter 6 of this manual
will discuss the associated interventions used to support and build psychological resources and skills.
Please refer to Appendix 3 for a full copy of the ARC and supplementary information.
Recovery Group Participation Scale (RGPS): This tool assists in the assessment of a client’s
overall recovery resources and strengths by measuring engagement with active recovery
communities. The RGPS will therefore constitute the assessment component for Phase 3 of the
Treatment Process Model (TPM) and Chapter 7 of this manual will discuss the associated
interventions used to support recovery and reintegration. Please refer to Appendix 4 for a full copy
of the RGPS.
Table 1: The Assessment of Recovery Capital Star and phases of the Treatment Process Model
Phase 1:
treatment
engagement and
motivation
Phase 2: building
psychological
Phase 3: recovery and reintegration
resources and
skills
Point 1 on
Recovery Star
Point 2 on
Recovery Star
Point 3 on
Recovery Star
Point 4 on
Recovery Star
Treatment
engagement
Motivation
Personal recovery
capital
Social and lifestyle Community group
recovery capital
engagement
Treatment
satisfaction
Treatment
readiness
Psychological
health
Substance use and Recovery group
sobriety
participation
Key worker
rapport
Desire for help
Physical health
Community
involvement
Risk taking
Social support
Life skills and
functioning
Housing and
safety
Treatment
participation
Point 5 on
Recovery Star
Table 1 above summarises the areas of assessment in line with the phases of the Treatment Process
Model. The Assessment of Recovery Capital Star (ARCS) can be used to help guide key workers to
ensure that they can provide the right kind of help at the right time in the client’s recovery journey.
It is important to recognise that the stage process of the ARCS is sequential and that the therapeutic
component of developing recovery capital rests on motivation and engagement. In other words, this
should be addressed and intermittently reviewed as the basis for all other types of change.
33
Chapter 5
TPM Phase 1
– Treatment engagement and motivation
5.1 Introduction
This chapter will provide information relating to Phase 1 of the Treatment Process Model, providing
guidance to key workers on how to use the mapping approach as part of building an initial
therapeutic relationship. It will then explore how care planning and care plan reviews are part of the
change process within treatment. This approach will predominately be used with new clients where
the aim is to build up a therapeutic relationship. However, it can also be used with clients who are
‘stuck’ or whose motivation has ebbed or the therapeutic relationship has weakened.
The primary approaches
The two primary approaches to engaging and motivating clients in this manual are based on:
• motivational enhancement models
• using the care planning and review process as a way of building a therapeutic relationship and
generating a set of shared goals and objectives that will inspire and motivate the client to
seek recovery goals and to engage in recovery activities in their community.
Motivational interviewing
There is strong evidence that supports the effectiveness of motivational interventions – brief
methods for engaging clients who are low in motivation to address ambivalence and uncertainty
about treatment. Work done in Birmingham has provided a tested approach to improving client
motivation, that will typically be used in the early phases of treatment although revisiting this may
be appropriate for clients who have got ‘stuck’ in the treatment process (Day et al, 2008). This
approach was used in the Birmingham Treatment Effectiveness Initiative and is based on a
sequential and phased approach to recovery working.
The assumption is that there are four therapeutic components in motivational interviewing:
1. Express empathy
2. Develop discrepancy – which basically involves identifying inconsistencies between the
individual’s substance use and their valued goals in life
3. Rolling with resistance – confrontation is avoided and it is the process of reflection that allows
the key worker to find opportunities for reviewing resistance and ambivalence
4. Support self-efficacy – the heart of the process is around promoting self-efficacy in the
process of change
35
From a recovery perspective, that means that the key worker is primarily engaged in facilitation of
self-directed change and works to increase motivation to change and to help the client channel this
into actions as outlined below. The key skills required of the key worker are consistent with the
values of a recovery approach and include:
• asking open questions
• listening reflectively
• affirming and empowering
• constantly summarising information
• eliciting self-motivational statements
5.2 Enhancing client motivation
Establishing the client’s current problems with addictive substances in a way that builds motivation
to change. Building motivation for change is important at any stage of the treatment journey, but
particularly so at the start.
Step 1: The initial task is to explore the client’s current drug use and their feelings about it. Adopt
an empathic approach to the client, without judgement or criticism. Acceptance of people as they
are frees them to change, whereas criticism may provoke the ‘Confrontation-Denial Trap’, in which
an adversarial response results and the problem is rejected or denied by the person seeking help.
By arguing too strongly for change, it is possible to push the client into a position of defending their
current actions. This is counter-productive, as the goal of the session is to elicit ‘self-motivational
statements’ from the client. In other words, people are more likely to act on intentions to change
that they have voiced themselves, rather than those demanded of them. A good way of starting this
process is by asking a very open-ended question about drug use:
“I assume from the fact that you have come to this centre for help, that you are experiencing
problems with drugs. What would you like to discuss?”
The goal is to get the client talking about their drug use as freely as possible, listening carefully to
what they are saying. Using Map 1.1 may be helpful to support this interaction.
36
Figure 9: Map 1.1 ‘My drug use’
Drug:
Things that are good about using
Things that aren’t so good
about using
Completing this list will help you prepare for the next map.
It is best to try to avoid asking too many questions, but instead ‘reflect’ the client’s words back to
them. Whilst discussing the client’s thoughts about their substance use, it is important to listen
reflectively. Reflective listening is a skill that has to be practised. The key worker or recovery coach
needs to let the client talk, but not lose control of the conversation. By deciding what to emphasise,
and what to play down, the reflective process can be used to accumulate a series of statements from
the client expressing their intention to tackle their problems. Using node-link maps will help key
workers in the reflective process, as it has the effect of slowing the process down (when things are
being written on the map), allowing the key worker to monitor what the client is saying more carefully.
37
Step 2: While it is important to acknowledge the benefits that result from drug use, one of the key
tasks for the key worker is to listen for self-motivational statements that can be reflected back to
the client. This can be supported using another structured map (see Figure 10):
Figure 10: Map 1.2 ‘Problems with my drug use’
What difficulties have you had
with your drug use?
What makes you think this is
a problem?
Example: you often think about stopping
My use of
In what ways have you or others
been harmed by your drug use?
How has your drug use stopped you
doing what you want to do?
It is important to persevere with this task so that as close to a comprehensive list as possible is
established. This can be re-visited as required.
38
Step 3: This is the detailed discussion of change from a motivational perspective and will involve the
implementation of motivational interviewing principles. At the heart of this is the idea of a decisional
balance, with the client having the opportunity to review the advantages and disadvantages of
continuing to use as shown in Figure 11:
Figure 11: Map 1.3 ‘Weighing it up’
Continuing to use as before
Advantages
Disadvantages
Making a change to my use
Advantages
Disadvantages
Step 4: Building towards change – this starts with attempting to elicit self-motivating statements
and working through these with the client, based on the statements made in the decisional balance
map (see Figure 11). The next step is to move forward to look towards the things that the client
really values in life. It is important that this is comprehensive and that the key worker tries to elicit
as extensive a list as possible – it might be beneficial to complete parts of Figure 12 as the person
suggests new things, whether these are people, things, activities, emotions or places that the
participant values.
39
Figure 12: Map 1.4 ‘What’s important to me?’
Places
People
Example: partner, children
Example: my house
Activities
Example: work, football
Things / Objects
Example: clothes, iPod
Feelings / Emotions
Things
that are
important
to me
in life
Example: happiness
Can you think of anything else?
Example: future goals
The client is then asked to rank these in order of importance so it is important that some time is spent
to ensure that the list is as complete as possible. The blank box is then completed with ‘primary drug’
and this is then fitted into the priority list of values. The aim of this process is to try to discover ways
in which the client’s drug use is inconsistent with their beliefs and values discussed in the first
part of the exercise. The key worker should listen carefully for statements that show a discrepancy
between the two, and record them as self-motivational statements, and should also listen out for
statements made by the client that indicate a need or a willingness to change.
This can be supplemented by asking the client where they are now and where they would like to be
at some point in the future, for instance, 3 or 5 years from now, which may also help the client to
consider any ambivalence about the role they see drug use as having in their long-term future. This
is particularly important within a recovery model as the aim is to encourage hope and ambitions and
to inspire planning that transcends the immediate circumstances and asserts a shared belief in what
is possible and what can be achieved in sustained recovery.
40
Step 5: The final exercise in this part of the manual aims for the client to consider the strengths
that they may need to make changes to their behaviour. In doing so, there is an opportunity to
reinforce and praise the strengths that they already have, thus reinforcing the idea that change is
within the client’s power. One way of doing this is by using the Tower of Strengths. The basic model
of the Tower is shown in Figure 13:
Figure 13: Map 1.5 ‘My tower of strengths’
Strengths I would like to work on developing
and supports I need
My strengths
E.g I am motivated
Supports from other people
E.g A supportive person
Strengths I know I have to help me deal with my problems
The Tower of Strengths is one of the most important maps in the manual – and should certainly be
revisited across the treatment journey. The key predictor of long-term recovery is ‘recovery capital’
and the central role of recovery interventions is to build the recovery strengths that will provide the
resilience, self-esteem and self-efficacy to support long-term change.
41
One of the key aims of the recovery approach is that the focus of interventions should be on
strengths and not on pathologies and it is important that treatment aims to build on the key
recovery capital factors that will promote sustainable recovery. For the Tower of Strength, the list of
key possible strengths is shown in Table 2 below:
Table 2: Suggested strengths
42
Adaptable
Forgiving
People-person
Adventurous
Friendly
Persistent
Ambitious
Funny
Polite
Artistic
Generous
Practical
Athletic
Good intentioned
Principled
Believes in self
Good memory
Problem-solver
Brave
Happy
Quick learner
Community minded
Hard-working
Quick thinker
Competitive
Healthy
Relaxed
Contented
Honest
Religious
Cool-headed
Imaginative
Responsible
Cooperative
Independent
Self-starter
Curious
Kind
Sense of humour
Dedicated
Likeable
Sensitive to others
Dependable
Logical
Sincere
Determined
Loving
Smart
Endurance
Loyal
Spiritual
Energetic
Mechanical
Spontaneous
Enthusiastic
Musical
Strong
Ethical
Optimistic
True to self
Even-handed
Open-minded
Trusting
Expressive
Organised
Trustworthy
Fair
Patient
Warm-hearted
Flexible
Peacemaker
Ask for examples of these as you go along, and reinforce the positive nature of these examples.
Continue by asking the client to suggest other strengths to supplement the list. Up to 10 words or
phrases are need to complete the bottom half of the Tower – if more than 10 are highlighted, try to
rank them and select the top 10. This is a good point to ask the client to complete the top part of the
tower – with those strengths they wished they had from the list. The second phase of the approach
ends with you drawing together the key strengths and goals from this stage of the process.
To help the person develop these strengths, it is essential that a context of social support is
established in which the therapeutic alliance is seen as a strength and strength-building is seen
as partly a personal growth experience and partly as a consequence of developing confidence in
belonging to recovery communities and groups. Thus, the personal aspects of recovery strength
will generally emerge from personal and social supports.
Step 6: Developing a plan of action: this starts with you working together collaboratively to select a
problem that you can work on jointly, based on the discussions and the maps from the earlier steps
of the process. The aim now is to use a motivational approach to work together to identify a
strategy for tackling this issue. The kind of questions that Miller and Rollnick (2002) have identified
from their work on motivational interviewing to address this stage include:
• What could you do now to tackle these problems?
• It must be uncomfortable for you, struggling with these difficulties. What is the next step?
•
What do you think has to change?
• What could you do? What are the options?
• What concerns you about changing your drug use?
Ideally, these questions are posed when the client is actively aware of their problems and is ready to
address them. The next step is to begin to develop a plan of action.
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5.3 Engaging clients in treatment
Most key workers in Lanarkshire’s alcohol and drug services will have considerable experience in
developing care plans but the aim of the remainder of this chapter is about how to translate care
planning into recovery planning, based on client empowerment and facilitative working. From a
motivational perspective the basic building blocks of switching to this model are outlined in Figure
14 below. This can be used to pull together many of the key elements discussed over the three
sessions. This should include the self-motivational statements elicited, the change that the client
believes could happen, the goals that move the client towards this target, and the potential support
that could come from others in achieving these goals. Finally, the last box projects into the future to
consider possible benefits of change.
Figure 14: Map 1.6 ‘Planning for change’
1. The change I want
to make:
2. The reason why I want
to make this change:
4. The first steps I will take:
3. My main goals for
achieving this change:
What:
6. The positive results
that I hope my plan will
have:
5. People who could
help me:
When:
What they could do:
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Recovery planning
Regardless of the baseline levels of motivation, a core source of direction and meaning will come
from the treatment planning process. This is the shared activity, at the heart of the treatment
process and will be the marker of progress that will allow a sense of shared achievement to emerge
from the work undertaken together by clients and key workers.
While the motivation process outlined above is crucial, for many people entering treatment is a
daunting process that seems to be based on the idea of listing all of the things that are wrong with
them and can set have a lasting, negative impact on the crucial therapeutic relationship. It is
therefore important for key workers to remember that the process of assessment and measurement
are not neutral, and can have a profound effect on how the client sees not only their problems but
also themselves.
Lanarkshire Alcohol and Drug Services will therefore need to ensure that the process and tools used
for assessment and measurement promote hope and emphasise the skills and strengths the client
brings with them to the treatment journey. Within a recovery focussed service, a key component of
the initial assessment is to achieve two things:
1. Mapping the strengths that the clients will bring to this shared endeavour which will then
assist in:
2. Setting clear goals for what the client wants and how to get there
This manual is designed to support workers in order to achieve these key tasks. The next set of maps
also focus on building motivation and building a therapeutic relationship and relate to the process of
developing and reviewing a care plan. This is to be a therapeutic process that builds a relationship and
engages motivation based on the client’s strengths and their commitment to change.
45
Figure 15 is a good place to start from a mapping perspective. It is a map of the person’s strengths:
Figure 15: Map 2.1 ‘My strengths’
Health and Physical
Where I live
Social Relationships
Example: my partner
What are
your strengths?
Emotions /
Coping Skills
Example: strong willed, calm
Values and Beliefs
Work and Skills
Example: worked in a shop
46
Example: motivation and
commitment to change
The idea of building on strengths is absolutely central to the recovery model and this is a map that
should be re-visited and updated at regular intervals. Building strengths will not only provide a
motivational foundation – the resources that are built here are central to the growth of the
therapeutic relationship.
Principles for strengths-based recovery planning
• The focus is on individual strengths rather than pathologies
• The community is viewed as an oasis of resources
• Interventions are based on client self-determination: in two senses – first it is individualised
and not to suit the programme and second it is the strengths from the client, supported by
the therapeutic dyad, that will predict success
• People suffering from a substance use disorder or a mental illness can continue to learn, grow
and change
David Loveland and Michael Boyle (2005)
Therefore, the success of the maps is the extent to which they complement the process of building a
supportive relationship and that they provide foundations for building and enhancing recovery
capital. Additionally, from their perspective of developing a recovery coaching model, Loveland and
Boyle (2005) believed that assertive community outreach as a key part of the delivery system of
recovery support. In other words, the maps have to be ‘portable’ and to be used flexibly in a range
of settings for the basic approach outlined in this model to be applied flexibly and meaningfully
across different parts of the recovery journey and process.
This can be cued with the list above but starting with the structured map and allowing the client to
identify his/her own strengths is a key process. These are the fundamental building blocks that will
support the client in their recovery and will allow the treatment dyad (the strengths base of key
worker and client) to launch the treatment components of the recovery journey. In combination with
the summary of the Assessment of Recovery Capital, this provides an overt statement of strengths
that are the basis for sustainable recovery capital. The mapping and planning of recovery capital is
an essential corollary to the next task which is around mapping where the client is and where they
need to go. Mapping where the client is at the start of the treatment process can be done using the
kind of guide map in Figure 16 or it can be done with a free mapping approach.
47
Figure 16: Map 2.2 ‘Me today’
Health
Interests
Relationships
Me today
Emotions
Work
Housing
The advantage of doing this as a free map is that it will enable the client not only to select the
headings but also their configuration and how they see them as linking together. This is an
important way of allowing the client to present themselves and for the client and key worker to
develop some shared meanings early in the process and it is suggested that, if possible, this is done
before the formal assessment process.
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Step1: Assess the individuals’ goals (Figure 17) and use their perceived strengths as part of the
process of realising these goals. The subsequent maps outlined are a way of unpacking that process.
In the first map, the aim is to outline the current situation for the client as a map of where they are
now, and to assess the extent to which substance use is at the heart of their problem profile. It is
suggested that the Assessment of Recovery Capital (ARC) and the Client Evaluation of Self and
Treatment (CEST) have already been completed to allow the key worker to input, particularly if the
client is reticent to add strengths into the discussion. The labels for each block can be replaced if
appropriate and it is important to bear in mind that this is simply the starting point of looking at the
clients’ issues and needs in terms of the strengths and resources that they can bring to bear.
Figure 17: Map 2.3 ‘Basic needs’
Treatment efforts to date
Severity of substance use
Education, work,
offending history
Emotions / temperament
Current
problems
and
resources
Housing and basic needs
Major strengths
Social support, family
Possible challenges
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Step 2 is to start translating the profile of problems into priorities to be addressed and the
strategies that should be used to address these. Figure 18 below is the start of this process of
identifying key areas where the client has a problem, and starts to unpack what the problem means
for them and what their goals are in relation to tackling this problem.
Figure 18: Map 2.4 ‘Goal planner’
Problem
area
Satisfaction
out of 10
What would have to change to
score 10 out of 10?
Priority
Drug and / or
alcohol use
Health (physical
and mental)
Social life
and friends
Relationships
Housing
Job / Education
Money
Exercise
Legal and
crime
You can add extra priorities or problem areas
if there are others for you.
In this approach, the client is cued with a total of nine areas and is asked to rate their satisfaction
with each on a score between 0 and 10, with 10 representing complete satisfaction and 0 complete
dissatisfaction. The third column is to be completed with what would have to be done to maximise
their satisfaction in that area and then to establish some priorities to be tackled. The final column is
where the client identifies the main three issues that they want to address in the initial phase of
treatment and the areas identified here are what will be prioritised and examined in more detail in
the subsequent map.
50
This links immediately to Figure 19 which is a map that takes the top three priorities (although it can
be less) for the client to start the process of unpacking the problem and thinking about their goals
in each of those areas. Thus, for the three problems, the client lists the problem area, describes it in
a bit more detail and then establishes a preliminary goal for tackling this problem:
Figure 19: Map 2.5 ‘Recovery plan’
Priority
Area
E.g Poor housing
Describe the
problem
Living in flats
surrounded by
people using
drink/drugs
Goal for tackling
the problem
Make appointment with
housing officer
Date to
achieve
Tomorrow
Loveland and Boyle (2005) give an example around jobs and education where some of the initial
goals might include learning how to use a computer, buying the appropriate tools; where assets
might include previous work experience, enrolling in a training or education programme or having a
driving licence and where the barriers to overcome might include previous convictions, no transport,
or ongoing health problems. However, part of the mapping process is to unpack and address these
based on the strengths package identified.
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One of the key tasks at this point for the key worker will be to supplement the initial list of
‘strengths’ with further exploration of social supports available to the client. These include those
provided in the recovery community, treatment service or their own family, community group or
treatment as well as a kind of list of local community resources identified as a core part of service
provision by Repper and Perkins (2003).
Step 3 is then to identify the highest priority problem and to work through it. Figure 20 is a
strengths based map which works with the goal identified in Figure 19 and asks the client to identify
what key strengths they have (personal recovery capital) and the helpful people and thoughts
(family and community recovery capital) that they will be able to draw on to achieve that goal. So
before looking at breaking down the tasks, and especially before looking at possible obstacles, the
key is to identify an ‘inventory of strengths’ that they will be able to bring to bear in addressing this
problem. This can then be repeated for the other priority tasks although it is important that
progress is made in small steps.
Figure 20: Map 2.6 ‘Making changes’
Specific actions
When
My goal
Helpful people & thoughts
Strengths
Possible problems
Solutions
Now look at each of your goals and decide which one
you intend to start with.
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By this stage, the client and key worker should be clear about the personal and social resources
that the individual has at their disposal to address the priority issues that has led the person to
come into treatment. This is in effect the process through which the key worker helps the client
to shape recovery actions and goals.
Supporting the recovery planning process
Loveland and Boyle (2005) offer some suggestions for key workers that will enable them to support
the recovery planning process in terms of their attitudes and perceptions. These include:
1. View the client as the expert on their life, goals and recovery plan, and that the key worker’s
role is as a consultant and support
2. Be enthusiastic about talking about goals, assets and positive attributes
3. Be patient with people who may be fearful about sharing their hopes and dreams
4. Ask open-ended questions that wont simply lead to ‘yes/no’ answers
5. Ask for specific timeframes or frames of reference (this is consistent with SMART objectives)
6. Probe answers for more detail to better understand the behaviours
7. Maintain the natural flow of conversation
8. Use active listening skills
It is also important that the key worker recognises themselves as a part of the strengths package –
this is not just a set of ‘homework’ for the client, it is an active part of the key worker’s role to
support and enable and facilitate this process. Achieving the foundations of recovery capital
(outlined in chapter four) is about helping clients to overcome barriers to access the services they
need and the resources that are available, especially those in the communities they live.
The key worker has three primary goals here:
1. To help the client clarify the skills and resources they need to achieve their goals
2. To locate the resources or identify the interventions or external supports that are needed and
help to plan how these can be acquired
3. To help the client attaining and sustaining these building blocks for recovery
It will be imperative for Lanarkshire Alcohol and Drug Services to have access to a comprehensive
and accurate list of local resources and supports that are available for their clients to access and
draw upon and that the service has connections with the enable clients at the early stages of their
recovery journeys to engage with resources and support.
In Chapter 7, there is discussion around ‘assertive linkage’ but what this means is that the inventory of
local supports and resources should be supplemented by contact names and telephone numbers of
contact points and ideally of peers already engaged in these activities and services who will be able to
introduce the client to these supports. One of the main reasons that community groups and treatment
services should be active participants in their communities is to enable and support this kind of
activity. If you are involved in a service that does not provide for all of the clients’ needs all of the time,
then it is important you have links to services that can go some way to meeting this challenge.
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Chapter 6
TPM Phase 2
– building psychological resources and skills
6.1 Introduction
As soon as there is evidence from the Recovery Star that the client is motivated to recover and is
engaged in a strong therapeutic relationship with the key worker and service, the model suggests a
transition in focus to the development of personal and social recovery capital. These factors are not
going to be sequential – rather they will be dynamic and mutually generative – and so the focus on
psychological and personal recovery capital factors is part of a process of developing overall
recovery capital.
Whether this is where the resources in treatment should be focused will be determined by what the
profile of scores is on the Assessment of Recovery Capital Star (ARCS). The factors addressed in this
chapter relate to phase 2 of the Treatment Process Model but are not sequential. Which issues are
selected will be determined by how the client scores and what they see their priorities as being.
Key concepts
Self-esteem - appreciating your own worth and importance
Self-efficacy - believing you have control over your world and can make things happen
6.2 Self-esteem
Within the recovery model, one of the core aims of therapeutic interventions is to provide clients with
the resources and supports that they need to build recovery capital. The assumption is that the
personal strengths and attributes - a positive identity, self-esteem, self-efficacy and life and coping
skills – derive from experience and the supports of others, including the key workers they engage with.
The first section deals with techniques for supporting clients to build self-esteem where they have
identified this as a problem or where this has emerged from the clinical process. This may be a
particular issue for long-term treatment clients who may have become ‘institutionalised’ by years of
prescribing with little positive intervention added.
What is self-esteem?
Our thoughts and feelings about ourselves are based to some degree on our daily experiences.
Things such as the day we’ve had at work, how our friends and family treat us or the ups and downs
of a romantic relationship can all have an effect on how we feel about ourselves. Our self-esteem
helps us manage these ups and downs. Healthy self-esteem is based on our ability to look at
ourselves accurately and realistically and still be able to accept and value ourselves. This means
knowing our strengths and our limitations and accepting that while we all have things we need to
work on that doesn’t mean we are a bad person, we are still important.
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People with low self-esteem often focus upon what they are doing in the present or their current
circumstances to determine how they feel about themselves. For example, if they are trying to fix a
broken object and it’s not going well, they may criticise themselves and believe that they are
worthless because they are finding it difficult to achieve what they want. The aim of working on
self-esteem is to build a core of self-esteem that is not linked to the daily successes and failures of
everyday life and that will allow your clients to take knocks without thinking they are worthless.
This will be a gradual process, most of which will evolve in their daily lives and both the key worker
and the client need to be clear that each of these tasks is to start a developmental process that will
continue outside and long after treatment.
Self talk
Self talk is what we say to encourage us or allow ourselves to put ourselves down and become
discouraged and give up. If we have high self-esteem, then these messages tend to be positive and
reassuring and encourage us to keep on trying at things we find difficult. Even if we fail at what we
wanted to do, high self-esteem means that though we may feel disappointed we still value ourselves
and feel that we are good person. In contrast, if we have low self-esteem we become our own worst
critic, with nothing we ever do being good enough. We may feel like this even if other people think
our work is good, if our self-esteem is low we may not be able to accept genuine praise from others.
Figure 21: Map 3.1 ‘High and low self-esteem’
Joanne, is on a DTTO.
She’s started college to retake her
Higher Maths. She has just taken her
Maths prelim. She got an F and
she’d hoped she’d get a C.
If Joanne has HIGH self-esteem,
what might she say to herself when
she receives her F grade?
If Joanne has LOW self-esteem,
what might she say to herself when
she receives her F grade?
Adrian, has been looking for a job.
He gets a letter inviting him to a job interview.
Adrian wants the job but gets
nervous in interviews.
If Adrian has HIGH self-esteem,
what might he say to himself once
his read the letter?
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If Adrian has LOW self-esteem,
what might he say to himself once
his read the letter?
How do we end up with low self-esteem?
How others treat us and how we see ourselves has a huge effect on our self-esteem, particularly in
childhood or if we have been abused at some point in our lives. The people around us such as our
friends, family or even teachers can influence the ideas that we have about ourselves. This is
particularly true when we are children. For example, if a teacher only tells a child when they’ve done
something wrong and never praises them when they get it right, then the child may believe that
they are not good enough and that they don’t know how to get things right. That child may go on
believing this and grow up still thinking that they aren’t good enough. Criticism may also come from
within us, with our inner critic finding fault with the things that we do. We may not be able to see
when we’ve done a good job or even that we are a good person because we may have unrealistic
expectations of ourselves believing that we should always get it right and that we must achieve
perfection. We may look at other people, thinking how much better they are than us forgetting that
nobody’s perfect and that everyone makes mistakes. Low self-esteem can have a powerful negative
effect on our lives. It can affect us in several ways:
1. It can cause us stress and anxiety and make us more likely to become depressed.
If we feel that we are never good enough, then we may feel under pressure from others to be
something that we think we’re not.
2. It can cause problems in our friendships and our relationships. If our self-esteem is low
then we may find it hard to accept compliments or attention from others.
3. It can lead to decreases in our performance in our jobs or our academic performance.
4. It can lead to underachievement. If we are afraid to fail then we may give things up when
the going gets tough. We may tell ourselves that if we don’t try we can’t fail. But if we don’t
try we can’t succeed either.
Figure 22 on the next page uses everyday examples to provide four illustrations of the impact that
negative self-esteem can have. The negative consequences of low self-esteem reinforce negative self
images. For example, Suzi gets so stressed out about getting it wrong that she messes up something
important and this of course stresses her out more. In Peter’s situation, Julie eventually has enough
of Peter rejecting her compliments and she breaks up with him. Peter then feels he was right, Julie
can’t have ever really liked him else she wouldn’t have finished with him. So, low self-esteem can
lead into a downward spiral, making our self-esteem lower and lower.
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Figure 22: Map 3.2 ‘Effects of low self-esteem’
Suzi’s situation:
Suzi’s thoughts:
Effect on Suzi’s life:
Peter’s thoughts:
Effect on Peter’s life:
Joanne’s thoughts:
Effect on Joanne’s life:
Alison’s thoughts:
Effect on Alison’s life:
A friend has helped
Suzi find a new job as
a receptionist but
Suzi thinks she won’t
be able to manage
the work.
Peter’s situation:
Peter and Julie have
been seeing each
other for 4 months.
Peter really likes Julie
but can’t understand
why she likes him.
Joanne’s situation:
Joanne is disappointed
that she got an F grade
for her maths test.
Alison’s situation:
Alison has been taking
driving lessons so that
she can legally drive.
Her instructor thinks
she should put in for
her test but Alison is
afraid of failing.
How to boost self-esteem
Self- esteem has been described as a social vaccine which can protect us against self-defeating
behaviour. So what can you do to boost your clients’ self-esteem? Before we can work on selfesteem the client must first believe that it’s possible to change it. Doing this can take time and
doesn’t always happen quickly or easily BUT boosting self-esteem is worth it. There are three steps
that can help improve self-esteem.
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Step 1: Challenge the inner critic
This means challenging the negative messages in your thinking and your descriptions of what you
do. Because our inner critic comes from us, then we can take back control and fight back against
self-criticism.
Figure 23: Map 3.3 ‘Building your self-esteem’
Negative message
Makes generalizations:
Challenging message
Is specific:
“I didn’t get the job I went for. I’ll never
get a job, I don’t have anything to offer.”
“I wanted that job and I didn’t get it but
that doesn’t mean that I’ll never get a
job, I’ve got jobs before, so I know that
I’m employable.”
Makes small upsets into big problems:
Looks at things realistically:
“He doesn’t like the CD I bought him. He
must think I have awful taste. I never
give good presents, I’m such a bad
friend.”
“I’m disappointed that he doesn’t like
the CD but he usually likes the stuff I
get him.”
Makes illogical leaps:
Challenges illogical thoughts:
“She’s looking at me funny. It’s ‘cos she
knows I use. She thinks she’s better
than me. ”
“Yeah, she is pulling a face, but I don’t
know why. She might be having a bad
day, that doesn’t mean she’s looking
down on me.”
Is too harsh:
Be reassuring:
“My tutor said that my work was
good, but I think it should have been
better. I can’t see how they didn’t
notice how much was wrong with it.”
“My work was good. It might not have
been perfect but I’m still learning and I
did a good job. I should be proud of
myself.”
Negative messages you use:
How you can challenge this:
Much of the key to step 1 is learning when the inner critic is speaking and learning to fight back and
not to catastrophise! The next step after this recognition is to start the process of appreciating
yourself.
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The way people explain things is called their ‘attributions’ – their understandings of what the causes
of events are. In this context, the most important thing is about how people explain their successes
and failures. Where successes are explained in terms of personal strengths and resources, they are
more likely to be built on (this is called internal attributions) as this is how self-esteem and
self-efficacy grow.
Step 2: Practice self-appreciation
This means the client must learn to recognise that they are a worthwhile person. Learning this can
take time because we may have been telling ourselves that we are worthless for such a long time
that it has become like a bad habit, i.e. it is automatic and we find ourselves doing it without even
thinking about it. Learning to appreciate yourself can involve:
• Practising basic self-care like eating healthily, getting enough sleep, getting exercise
and looking after your appearance. It might sound simple but if we look after ourselves
then were less likely to let bad situations get to us. If we are tired or hungry we may find
difficult situations a lot more upsetting and frustrating and blame ourselves for things that
really aren’t our fault. When we are feeling physically well, we are in a better position to look
at situations clearly.
• Doing fun or relaxing things to help yourself unwind when you find something
frustrating. Rather than blame ourselves for things that go wrong we can do positive things
to make ourselves feel better. Sometimes people may feel that they need to use (drugs) to
make themselves feel better. However once the effect wears off they are disappointed with
themselves for letting themselves down and this can make their self-esteem even lower.
Treating yourself to something positive might mean going out to the cinema, getting yourself
a new item of clothing, doing something that you enjoy but won’t regret the next day. Use
this as an opportunity to mention activities in your service e.g. learning baby massage or
taking part in sports.
• Reminding yourself of your strengths and achievements. When things go wrong we can
try and think of things that have gone well in the past for us. We can also think about the
good qualities that we have.
Much of what the recovery approach is asking the key worker to do is to build on strengths and it
should become second nature for both key worker and client to start from the base of positive
achievements. But it is also part of the model to look to a broader recovery alliance based on social
capital to bolster the personal growth and provide the safety and security to allow self-esteem to grow:
Step 3: Getting help from others
People who have low self-esteem often won’t ask others for help because they feel that they don’t
deserve it. But getting help from others can be a really important step in improving your selfesteem. Talking to someone can help you vent your frustrated feelings. There is an old saying ‘a
problem shared is a problem halved’. Just by talking to someone we can feel a bit better and more
able to deal with problems. Also the people who know us can help us think about our good qualities
and the things that we’ve achieved. If you feel that your client may need some help and support
with developing their self-esteem, encourage them to talk to their identified people of support.
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These supportive individuals can help your client build on his/her strengths by recognising them and
recognising the role they will play in helping your client to move forward. It is critical that the client
does not think they are on their own. There are three resources you should emphasise:
1. Their existing family and support groups
2. You as their key worker and your colleagues
3. The recovery and mutual aid groups in the area that you can link the client into.
Figure 24 below summarises much of what should have been learned in the course of this session.
Boosting self-esteem takes time, effort and energy but is really worth it. By taking time out to boost
self-esteem, the client may discover new positive things about themselves that make them appreciate
themselves and grow. It is also important to come back to these maps as the client experience lows
and to recognise what they have already achieved and what that has been based on.
As with all of the mapping exercises in this manual, these are not one-off exercises that are
forgotten, they are parts of a portfolio of recovery and both key worker and client should keep a
copy of all of these as ways of charting the stages of the recovery journey and reflecting on their
role in enabling and sustaining overall recovery, through setbacks and problems.
Figure 24: Map 3.4 ‘Improving self-esteem’
Ways I can look after myself:
Things I can say to challenge
my negative self talk:
What are my strengths
and achievements?
Who can I talk to
for support?
Things I
can do to
improve my
self-esteem
Things I can do to treat myself
when I’m feeling down:
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6.3 Self-efficacy
Linked to growth of self-esteem is the idea of building self-efficacy – believing you have control over
your world and can make things happen. Self-esteem alone is not enough. The sense of
achievement and capability is the next step in the process of enabling recovery growth. This has
links to problem-solving skills where the challenge is to translate a desire to make something
happen into enabling that change. Again, this may be particularly important for clients who feel
‘stuck’ in treatment and who do not know what to do to move forward.
For many clients, it will be problems around the key self-concepts – efficacy, esteem and identity –
that are keeping them stuck in a rut. One of the core challenges of the therapeutic recovery
champion (please see pg 11 for more detail) will be to build up psychological strengths to enable
and empower clients to take on the challenges of coping with relationships, finding new partners,
entering training and employment, and achieving sustained recovery. Building up self-efficacy does
not guarantee success but it empowers the client to try things so it is an area where the key worker
and the other individuals who are part of the recovery capital portfolio of the client have a key role
to play. In the first version of the task, we attempted to outline the challenge that the person faces
and it may well be that this will follow from the completion of the ‘Brick Wall’ task in Figure 25 if the
problem is about the client’s perception that they can’t do it! The first task is a clear articulation of
the goal that is being blocked and what it is that appears to block the goal.
Figure 25: Map 4.1 ‘Identifying the blocks’
Goal being blocked:
Who can be recruited
to help?
Can it be broken
down into tasks?
What is the
block to achieving
the goal?
What are the skills required
and what strengths do
you have?
What can you learn
from this?
Alternatives to my problem are...
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How have you achieved
similar things?
The basic principle is to use a cognitive approach to breaking down a seemingly unmanageable task
into achievable component parts and then to identify ways of tackling each. But this is embedded
within a relationship built on strengths and on recovery capital. So the key questions to address with
the client are:
1. What are your skills and strengths that are relevant here?
2. What have you previously achieved using those strengths?
3. Who are the key individuals who can help or teach you any strengths or methods you don’t
currently have?
4. What are the other resources available in the treatment service?
5. What are the resources available in your recovery community?
6. How do we translate this into an initial plan of action?
For both self-esteem and self-efficacy, the long–term strategy will be indirect with success and
subsequent reflection contributing to building psychological strengths but there is also the
opportunity for the therapeutic recovery champion to work overtly on this topic using the key
questions above as the building blocks.
Figure 26: Map 4.2 ‘Building skills and strengths’
Your aim:
Possible choices you
can make:
Consequences
of choice:
Resources you can
draw upon:
Strengths you possess:
Barriers:
Deciding on your strategy
Which choice
seems best?
Implementing your plan
and reflecting on what
you can learn about your
strengths and resources
Negative
Consequences of choices
Positive
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When using this map, it is useful to revisit Map 1.5 My Tower of Strengths (please see Chapter 5)
and if this has not been done previously, to use the strengths map as part of the process of building
both self-esteem and self-efficacy. Remember that this is not simply a list of personal qualities, but
also of experiences, knowledge and previous achievements. This wider map of strengths links to the
Recovery Star – it is therefore important to prompt the client to consider their strengths and
supports (recovery capital) in all of these areas:
- Personal recovery capital
- Motivational capital
- Social recovery capital
- Therapeutic alliance and treatment resources
- Recovery group membership capital and the resulting sense of identity and belonging
As there are fundamentally social components to the therapeutic and group participation elements,
social capital is therefore the most important area to explore within the recovery 'capital' model.
From a recovery perspective, the opportunities for growth in self-esteem and self-efficacy are
embedded within the growth of recovery capital and the building up of resources that allow the
person to choose and learn. A summary map for working around self-esteem is given in Figure 27
opposite.
6.4 Building a positive identity
A recovery journey is based on hope and growth and this involves changes in the way that the client
views themselves, their lives and their relationships with families and friends. One of the key roles
for the key worker is to help by actively exploring values and goals, and allow clients to explore the
options that build recovery identities.
Other people may have negative perceptions about us, and these beliefs may over time come to
erode our self-esteem and sense of worth, even when these negative perceptions are not a
reflection of our own qualities. Nevertheless, we may identify with these perceived negative aspects
of our behaviour – and not question the negative thoughts (e g self-criticism, anxious predictions)
which may maintain the process of identification with others’ negative perception about us.
Recovery involves building and strengthening a balanced sense of self, for example by
monitoring/noting positive qualities and learning to treat oneself as a person worthy of respect and
care. Building a positive identity involves testing positive and negative thoughts about one’s identity
and it is based on the concrete evidence (specific experiences) of the clients’ everyday life.
The task that you might use involves the client generating a list of up to 10 desired qualities and
then rating (1-100) how much they believe they possess these qualities and generating concrete
examples. The kind of things you might want to consider in this list are:
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- Loyalty
- Integrity
- Determination
- Kindness
- Achieving
- Supportive
- Being positive
Figure 27: Map 5.1 ‘A positive identity’
Quality I would
like to have
Sense of calm
My rating
(1-10)
7
An example of
how I display this
quality now
I did not get upset or angry
when my partner came
home late last night.
How can this
help you in
your recovery?
I can cope with
angry, upset or
difficult feelings.
Prompts should only be provided if the person is struggling to come up with their own list.
The experiment can be extended as a homework task where the client is asked to select 1-2
qualities, and monitor behaviour and record evidence for specific positive characteristics. Re-rate the
belief in characteristic at the next recovery progress review session. It may take some time for the
experiments to have impact. It is important to encourage persistence and so that the client does not
abandon them prematurely if there is no immediate effect. Supporting the person to get into the
habit of tackling negative assumptions builds day-to-day changes. The cumulative impacts of many
experiments over time can be significant.
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There are no quick solutions to these problems but whether these sessions take place in formal
treatment settings or in the community, the aim is the same and that is to build recovery capital
that is internalised but is developed and made manifest in social contexts. It should also mean
that both the key worker and the client end each session feeling positive and building towards
further sessions.
Building a positive identity is a crucial part of the recovery journey and the emergence of a recovery
identity that is not immersed in guilt and shame around using is essential for this process.
The recovery principles map in Figure 28 is part of this process of developing a recovery identity.
The purpose of the map is to allow emerging parts of the recovery identity to be made explicit as
part of a change in values and beliefs.
Figure 28: Map 5.2 ‘Recovery principles’
What are your internal recovery strengths?
What are the things that inspire you?
What recovery values do you hold?
What successes can you build on?
What can your recovery guides do to help?
What gives you hope?
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This is part of a process of supporting the change from an “addict” identity to a recovery one.
This will not happen overnight and will require considerable support and guidance. The final map in
this section, highlighted in Figure 29, is designed to support that transitional process and it is one of
the maps that is crucial to come back to as progress is made and the client’s self-perception shifts
towards the roles and activities and resulting identities associated with recovery.
Figure 29: Map 5.3 ‘Recovery identity’
What are the bad
things about using you
are leaving behind?
What are the
good things about
recovery?
What new doors
does this open
for you?
How has it changed how you see yourself?
And what else do you need to grow your recovery self?
Overview of psychosocial change
The purpose of this section is to provide tools that allow clients to explore core aspects of selfchange as part of the recovery journey. These are markers in a recovery pathway that provide
support and guidance as the client’s identity grows in recovery and as the client begins to establish a
sense of control and mastery of themselves and what they do. However, this is not an abstract task
and is the basis for active engagement in the community. The next chapter is about how these
personal transformations are acted upon and supported in the wider community and examines
recovery processes as they occur in communities of recovery, in families and by the person in
recovery engaging in the long-term aspects of recovery growth.
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Chapter 7
TPM Phase 3 – Recovery and reintegration
7.1 Introduction
This chapter reflects the third phase of the Treatment Process Model, targeting effective
reintegration and recovery. Although presented in this sequential manner, it should be apparent that
this is an ongoing process that should have started with the initiation of treatment and that will
continue significantly beyond the end of any formal intervention as the client continues to develop
and grow, as evidenced by changes in their recovery capital.
This stage is made manifest in the form of markers of recovery – safe and stable accommodation,
rewarding and supportive peer and intimate relationships and meaningful and rewarding activities.
However, there are two linked layers of change that are the foundations that will underpin these
achievements. These are:
1. psychological growth – increased self-esteem, self-efficacy, coping and resilience
2. the development of a recovery identity and the linked social networks who are part of the
shift in perceptions and social constructions
This chapter is about the processes of moving to a non-addict identity that is linked to recovery
communities and support groups and translating the building blocks of psychological growth into the
enactment of recovery across a range of non-treatment settings.
The initial sections of this chapter are based on the “Straight ahead: transition skills for recovery”
manual developed at Texan Christian University by Bartholomew and Simpson in 1993. As such, the
original target group for these interventions were those who had been successful in quitting or
substantially reducing their drug use. As part of the process, the authors suggest that clients keep a
Weekly Recovery Journal – a single page for recording successes, challenges and goals around
specific recovery issues. To introduce this, the authors recommend an initial discussion on the nature
of recovery and Figure 31 highlights a useful map to use at this point.
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Figure 30: Map 6.1 ‘What is recovery?’
Spend more time
with people who
don’t use
Learn
new skills
Be open to
new ideas
Do what works to
avoid cravings
Ask for
support when
you need it
Develop
drug free recovery
networks
Resolve anger, guilt
and frustration about
past drug use
Not using
– no matter what
Find new and
enjoyable social
activities without
drug
Get involved: job,
school, hobby,
pastime
Change attitudes
about drugs and
drug users
What does recovery mean for you?
As your recovery journey progresses, so may your aims and goals.
You can come back to this map and look at how your
recovery goals change if you need to.
7.2 Exploring a recovery identity
For many clients, particularly those who have been in treatment for long periods of time, much of
the early work will be around raising awareness that recovery is possible and encouraging them to
consider what recovery might mean for them.
The aim of using the map within Figure 30 is to help to raise recovery awareness and to link this to
personal aspirations. It also should provide the basis for encouraging the client to think about what
applies to them and how they can make use of these concepts and principles within their recovery
plan. You may want to revisit Map 2.5 Recovery Plan (see Chapter 5) after this exercise to see what
may have changed. The next stage of this process is to generate discussion around activities and
resources (forms of recovery capital) that can be deployed to maintain the recovery journey.
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Because recovery is a lived experience, the meaning of recovery will not only differ from one
person to another, it will also change for a person over the course of their recovery journey.
For clients who are not familiar with the concept, this may mean that the key worker will need to
provide some cues and guidance in the initial discussion of what recovery means as shown in Figure
31 and again this is a map that should be revisited as the client progresses in their recovery journey.
As their awareness of recovery grows, all of the cells should be empty and all should be filled in by
the client. What they put in each of the cells can then be linked to the recovery planning process
and the reviews that are undertaken.
Figure 31: Map 6.2 ‘Enabling recovery’
How will you stop using all drugs and stop being around drugs?
How can you avoid people and situations
that trigger your desire to use?
Can you ask a non-using family member or close
friend to be your ‘partner’ in recovery?
How will you go about forming a self-image
of yourself as a Person in Recovery?
What can you do to plan your time and stay busy?
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For those who have been in treatment for a while, there may well have to be a gradual process of
‘awareness raising’ and as the early goals of recovery in treatment are met, so the client should be
encouraged to aspire to additional recovery objectives. As RETHINK (2008) have argued in the
context of mental health recovery, there are three precursors to starting a recovery journey. They are:
- a safe place to live that is free from threat
- relief from acute physical and psychological health symptoms including cravings and
withdrawals
- basic human rights including choices and decisions
So when the client is in the ‘pre-recovery’ phase of treatment it may be difficult for them to
envisage longer-term aspirations such as education and training, active community engagement and
long-term change but this is likely to change as their acute treatment needs are addressed. There is
an additional problem for clients in long-term maintenance who may have little idea of what
recovery looks like through their own personal networks. For such clients, there may be considerable
benefits in encouraging them to engage with people who are already established in their recovery
journeys. What the map in Figure 32 attempts to do, is to encourage the client to explore options
around recovery engagement:
Figure 32: Map 6.3 ‘Identifying a recovery network’
Who do you know who is in recovery?
What recovery activities do you
engage in with them?
How do they help
your recovery
How could they link you to
recovery groups?
What could you do to engage
with others in recovery?
How could you help their recovery journeys?
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Linking in to recovery networks is a crucial part of a recovery journey for most people. In the
recovery studies done within the UK (Best et al 2008, 2010), none of the 800 recovering or
recovered individuals interviewed reported that they had done it on their own and recovery is a
fundamentally social process. If the individual has no contacts at all who are engaged in recovery
process it is essential that they are supported to make contact with peers who are in recovery.
Figure 33 highlights a map which is about encouraging individuals to engage with a mentor or guide
who can support their recovery journey.
Figure 33: Map 6.4 ‘Recovery guides’
What can you learn
from them?
What supports can
they provide?
Who is the
person you know
who has made
most recovery
progress?
What do they do
that you could do?
What are the challenges you
face to get what they have?
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Litt and colleagues (2007) have shown that actively engaging people with network support has
marked benefits in reducing the rates of relapse in recovering individuals – where former drinkers
engaged with sober networks there were marked reductions in their rates of relapse. For those who
do not know individuals who are not active users, it is essential that the service has assertive linkage
to recovery groups where the individual will have the opportunity of engaging with people who are
sober. As White (2007) has argued, the benefits of engagement in social networks of recovery are
that they offer:
• Experience of acceptance and belonging
• Build esteem through identification with a large organisation
• Provide a belief system through which shame and defeat can be transformed into victory
• Provide a vehicle for the safe discharge of powerful emotions
• Provide a consistent set of rituals that facilitate emotional release and value-focusing
• Provide a forum for consultation on daily problem solving
• Provide rituals that allow the group to celebrate success
One of the primary aims of the reintegration component of the Treatment Process Model is to
enable clients to be involved in a range of recovery activities and groups. For many individuals, there
may be some hesitance or reluctance about attending 12-step groups that will need to be
addressed. The map within Figure 34 is about addressing these concerns:
Figure 34: Map 6.5 ‘Overcoming barriers to 12 step groups’
What are the groups in
your area?
Where would you
get info?
Who do you know
who attends?
How would you find
someone to go with?
What are the barriers
to you attending
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The idea of assertive linkage to mutual aid groups is based on research (Timko et al, 2005) which has
shown that simply giving people leaflets or directing them to meetings is not sufficient. If you want
people to attend mutual aid groups it is essential to actively promote attendance. What this means is
offering people contact with someone from the group who will talk through what is involved and who
will take the person to their first meeting. The evidence would suggest that not only will this increase
the likelihood of them attending, it will also increase the chance that they will subsequently go back
(Gow et al, in press). Research in Glasgow (Best et al, in press) has suggested that it is the
development of a sober social network that is crucial to recovery and the transition from using
friends to those who are in recovery that is a key part of the sustainability of recovery. As part of the
recovery process, the client needs to consider how they are going to develop and maintain a sober or
recovery network and the map within Figure 35 supports initiating this discussion.
Figure 35: Map 6.6 ‘Sobriety networks’
Who do know who is clean and sober?
When can you next see them?
What can you do with them?
How can you get them to
help your recovery
What keeps them
clean and sober?
What can you learn and talk to them about?
This is a key group of people who will support the client outside of treatment hours, who will help
to engage them in sober social activities and who will enable the gradual transition from the culture
of addiction to the culture of recovery.
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7.3 Being active in recovery
While it has been estimated that the typical journey to stable recovery is around 5-7 years after the
last use of heroin, and 4-5 years for alcohol, there are many practical and immediate steps that can
be taken and one of the key tasks is to encourage clients to make each day a recovery day and to
plan recovery activities as part of the routine process of a recovery journey. Figure 36 highlights a
map which is about working with the client to create a ‘recovery routine’.
Figure 36: Map 7.1 ‘Planning a recovery day’
What is the first step?
What strengths can you use?
What challenges will you face?
Who can you rely on today?
What can they do?
What rewards will this bring?
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The aim with this map is to focus on immediate recovery activities as the idea of planning a longterm recovery future can appear intimidating and daunting. This is consistent with the idea that
‘every journey begins with a single step’ and is about planning simple activities that might be:
• Seeking out a recovery coach or champion
• Attending or arranging to attend a recovery group
• Signing up for a training course
• Signing up for a recovery workshop
• Looking for opportunities to volunteer
• Dealing with ongoing health and wellbeing issues
• Planning a healthy meal
• Doing some exercise
The idea is that this can build into the kind of recovery diary that is outlined in the map within
Figure 37.
Figure 37: Map 7.2 ‘Recovery journal’
Week beginning Recovery
area
Success
Rough spots
Concerns
Goals
Staying clean
Recovery work
Social
relationships
Personal
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From a recovery perspective, the opportunities for growth in self-esteem and self-efficacy are
embedded within the growth of recovery capital and the building up of resources that allow the
person to choose and learn.
7.4 Building a recovery future
There are a series of questions and prompts that may be useful in encouraging the client to think
about the long term and to support them to make plans.
• What would your older and wiser self say is different about you since you started on this
recovery journey?
• How have you made that happen?
• Who else has noticed this change?
• How has it affected your relationship with them?
• How will you help yourself remember the advice from your older and wiser self?
The transition from formal services is a very difficult time for clients, particularly if their days have
been filled by a programme with all of the demands that this entails and the camaraderie and
support available from peers and friends. The client may feel that they are looking over the edge of
the cliff, particularly if they have had a strong and supportive relationship with you or with other key
workers. White (1990) suggests that one of the big challenges is to replace the core activities of
addiction with the core activities of recovery. He provides some guidance on how this might be
achieved:
• ‘centering rituals’ – routines that keep you focused during day-to-day activities, including
reading recovery literature or carrying symbols of your recovery; focusing and evaluating each
day; using meditation or prayer to seek strength; and self-commands where you identify and
challenge your own negative thinking
• ‘mirroring rituals’ which involve engaging with other people who share your recovery values
and will include contacts with mentors or recovery coaches and supports. This will also involve
attending meetings of recovery support groups and engaging in activities at these groups to
increase your commitment to them.
There is the option of doing some goal planning at this point, but there is also merit in starting to
plan for the transition away from formal support to foresee and plan for problems that can arise.
These might include the concerns about boredom, worries about bumping into old using associates
and being tempted or the difficulties of coping with responsibilities like childcare or dealing with
household bills and responsibilities.
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In Lanarkshire, we have built on the work developed by the
Scottish Recovery Network for mental health and developed
MyRAP (My Recovery Action Plan). MyRAP includes many
of the maps used in this manual and encourages clients to
plan their own recovery journeys. MyRAP also includes a
checklist of some of the things that people can do every
day to support their own recovery. These include:
• Planning what needs to do every day
• Staying in touch with family and friends
• Effectively managing personal care and
appearance
• Taking time out
• Talking to friends and family
• Complementary therapies
• Maintaining positive routines
• Reminding yourself of and utilising your strengths and abilities
Coping with daily challenges will also involve making the most of social networks and working out
how people can help (and how they can be helped in return), and working out ways of staying safe
when feeling threatened or vulnerable. The key worker can contribute to this by helping the client to:
• Make a detailed plan
• Remembering what has worked in the past
• Comforting and diverting activities such as music, exercise and resting
To encourage the idea that recovery is not just about stopping using drugs, but is about wider
lifestyle decisions and choices, the maps within Figures 38 and 39 are about actively encouraging
engagement in a range of lifestyle choices that will promote wellbeing and improve both functioning
and self-esteem and efficacy. Figure 38 encourages the client to focus on things that may not have
seemed a priority when entering acute treatment but for those engaged in long-term treatment and
those moving towards stable recovery, are likely to be crucial components of the recovery journey.
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Figure 38: Map 7.3 ‘Improving wellbeing’
The aim with this map is to encourage the client to think about how well they look after themselves
physically, psychologically and socially. These are also techniques for managing stress and for
providing energy for the tasks needed for recovery. Our ability to cope with stress and to handle
stressful situations is influenced by how good we feel and how well we take care of our bodies.
Below are some basic tips for promoting client wellbeing.
Get plenty of rest and sleep. Sleep problems are common during recovery so learning good
sleeping habits is a big priority both for stress management and for staying in recovery.
White (1990) has argued that, to promote satisfactory sleep in recovery, it is beneficial to:
• Eliminate consumption of caffeine and closely regulate nicotine intake
• Avoid napping during the day
• Engage in some form of aerobic exercise
• Eat a snack before bedtime
• Use relaxation techniques to lower the levels of physiological arousal
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Pay attention to nutrition – food is fuel. Encourage the client to try to eat more grain products
like rice and bread, more beans and pasta, and more fresh vegetables. They should try to go easy on
fats and oils, and to eat smaller amounts of animal products like meat, cheese, eggs and butter.
The best way to manage nutrition is through careful planning – so you should encourage the client
to reflect on:
• What are you eating already that is good for you?
• How can you make sure you continue to eat healthy foods?
Give up smoking if you can. As well as the risk of cancer and heart diseases, smoking may reduce
the body’s ability to utilise certain vitamins effectively.
Try to drink about eight glasses of water a day.
Exercise regularly. The standard recommendation is about 30 minutes of moderate exercise three
or four times a week. It helps if your exercise involves doing something you like. Regular exercise is a
proven stress-buster.
Relax, unwind and have fun. Taking time to relax and unwind each day is refreshing and it will give
you an edge when situations turn stressful.
The map within Figure 39 provides a basic planning format that can be worked through to follow up
on the map within Figure 38.
Figure 39: Map 7.4 ‘Health checklist’
My goal is:
First step:
My goal is:
First step:
My goal is:
First step:
My goal is:
First step:
Sleep
Nutrition
Exercise
Having
fun
Try to think about how to link these things into your daily routines
and make them part of your emerging recovery rituals.
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Part of the aim of recovery is as a means of reinvigorating a ‘spoiled identity’ (McIntosh and
McKeganey, 2002) and this involves a focus on self-image and self-respect. There is increasing
evidence that there are positive benefits to a recovery journey that focuses on improved diet, sleep
and stress management and that these will have a dynamic effect on motivating and energising the
client. Complementary therapies may also be a useful adjunct to this sense of wellbeing and in
triggering the client’s interest in their body and brain and so to further improvements in functioning
and self-identity. Spending time in social activities with peers in recovery may also be an important
aspect of triggering this ‘virtuous spiral’ in self-esteem and positive personal identity and should be
a source of fun and socialising as well as ‘work’ in the recovery journey.
7.5 Sustaining recovery journeys
Key workers will need to work with clients to help them start by getting the basic building blocks in
place. Having a clear plan of what the client is aspiring to is important and then to focus on the
more immediate steps for managing their recovery life on a day to day basis. One of the key
exercises emphasised in MyRAP is for how clients can plan how to:
• think simply and positively
• build positive routines
• focus on what makes you feel good
• think about what your responsibilities are
• think about the people that rely on you
• consider what your priorities are
The client should be encouraged to contrast the strengths they now have compared to the start of
the recovery journey and to focus on additional strengths and resources that they can draw upon:
- Family
- Friends
- Recovery groups
- Social activities
- Their own positive behaviours
- Personal strengths
- Positive qualities
- Their dreams and goals
- Their successes and achievements
- Their self-awareness
- Their role in the local community
- Their importance to other people
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The maps presented below are linked and are essential in mapping through recovery process and
recovery assets and the client should be encouraged to review this regularly and to consider their
recovery process. The map within Figure 40 encourages the client to create an ‘Inventory of
Recovery Assets’ and then the map within Figure 41 asks the client to consider how each of these in
turn could be used.
Figure 40: Map 8.1 ‘Building your recovery assets’
Who are
your assets?
How can they
benefits be a part of
What is good What
offer your recovery
about them? do they
you?
journey?
You
Family
Friends
Recovery
Groups
Community
Groups
Workers
Peers
Others
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Figure 41: Map 8.2 ‘Exploring recovery assets’
What aspects of your
recovery can they build?
For each
recovery
asset
What can you do to make
the most of this asset?
What are the opportunities
you have with them?
The purpose of this section is to both remind the client about the resources and supports that they
have developed in their recovery journey and to encourage them to think about how they can be
mobilised in the ongoing recovery journey.
Recovery groups and the recovery journey
In Scotland, there has been a lot of debate about Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA) in terms of whether they work and whether they suit everyone. The answers from
research are different to each of these questions:
In sum, there are a large number of research studies (mainly in the US but also in the UK) that
show that people who go to 12-step and keep going do better than those who never go or only
go occasionally. However, that does not mean they are suitable for everyone. For many people,
the timing may not be right and there are some people for whom the timing will never be right!
There appears to be confusion among some key workers and clients about mutual aid. There is a lot
of evidence supporting AA, some evidence supporting NA and a much more limited evidence base
around SMART and other forms of mutual aid group but this is not because these things don’t work.
This is only because, for a range of reasons, researchers have not attempted to measure their effects
and this is particularly true in a Scottish context.
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However, it is important to note that recovery journeys will, for many people need the support of
local community groups but that these will not all be ‘therapeutic’ in the manner that AA, NA and
SMART have an overt recovery philosophy and model. It is likely that people will need a basket of
activities and groups:
1. Therapeutic groups – to work through the recovery process and journey
2. Educational and vocational groups – to allow people to develop the skills and get the
qualifications that they will need as their aspirations grow in recovery and their long-term
aims evolve
3. Interest and activity groups – it is crucial that people have the opportunity to develop and
express their creative energies and find channels for physical and competitive urges.
While there are a core set of professional skills and expertise that has been insufficiently tapped in
recovery documents – including the skills of occupational therapists, social workers and education
and employability workers – they have to exist as the foundation stones for building and
empowering such groups and skills in community settings. The fundamental models of effective
community group and mutual aid approaches are based on the ideas of social learning and social
networks – that the effective engagement of people in recovery is based on the idea that recovery
is contagious in groups within natural settings and that the modelling of interests and activities has
to be primarily driven by peers.
For this reason, the nature of the interest groups – football teams, walking groups, guitar clubs,
dance lessons and so on – cannot be prescribed but must emerge from the interests and
enthusiasms of the peer group and ideally this will become a mechanism through which natural peer
leaders will emerge in the recovering communities.
So from the client’s perspective, key workers should work with them to address two big questions –
what is out there in your community that would inspire you and help your recovery journey and
what can you do to make things move forward around things you are interested in? The types of
recovery support that are particularly relevant are:
1. recovery mutual aid groups – including AA, NA, CA, SMART and other groups of individuals
in abstinent or maintained recovery – but the purpose of the groups is explicitly to maintain
each other’s recovery
2. vocational groups – this will include projects targeting education and training, but will also
include volunteering projects and other initiatives where groups of people in recovery meet
to support and develop their interests and skills
3. interest groups – this will be more typically sport or hobby groups such as football teams,
hill-walking clubs or dramatic arts such as music evenings and theatre groups
All of these groups will have a significant role to play at different points in the recovery journey.
While there are some resistance to engage with 12 step groups among both clients and with key
workers, it is important that clients are given the choice and are given information about mutual aid.
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The main benefits of engaging with mutual aid recovery groups are that they:
- help people with urges to use or drink
- provide support and understanding if setbacks occur
- provide a place to share and hear success stories
- help to fill up spare time
- introduce individuals to new people and ideas
- helps people to develop a supportive peer network of others in recovery
Some people are put off because the first group they attend does not suit them or they don’t like
the people who are there – so it is important to encourage clients to shop around and to ask for
advice from their peers – it might be worth working through a checklist of factors that might
influence their decision:
Figure 42: Map 8.3 ‘Mutual aid groups’
What other
types of
groups do
you need as
well?
Shop
around –
what do you
want?
Engaging
with
mutual aid
Prepare so
that you can
attend at
least weekly
Do you
need a
mentor or
sponsor?
What are your
‘warning signs’
that you
should attend?
Are the times
right for you?
Do you have
someone to
go with?
While clients may benefit from shopping around, many clients do not feel the need to stick to one
group and may attend a range of mutual aid groups and other community supports to fulfil
different parts of their recovery journeys at different times. Thus, it is not simply a case of linking
with AA or SMART, NA or volunteering groups but of linking clients into a range of supportive
activities they can engage with to meet different and often complementary needs. If the client
does want to go to 12-step groups, it might also be useful to ask if their partner or family
members would be interested in Al-Anon or other family support groups. Contact details for all
groups operating in Lanarkshire is available from the Lanarkshire ADP website
http://www.lanarkshireadp.org.
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• One of the ways that key workers can assist in recovery journeys is by assertively linking
people to local communities including recovery groups but also by working with these groups
to make sure that treatment and community groups communicate and have clear pathways
for mutual support, information sharing and enabling clients to be supported as they require.
There is increasing evidence (White et al, in press) that engagement in mutual aid groups will follow
different patterns for different recovery journeys – some people will remain lifelong members, while
others will move beyond and through 12-step and other mutual aid groups. This is likely to reflect
different patterns of growth of recovery capital but the evidence on this is limited at present.
However, there is a clear evidence base (e.g. Andreas and Callan, 2009) that the benefit of mutual
aid attendance is not limited to the individual attending meetings. Andreas and Callan found that,
where former drinkers attended AA groups after completing treatment, their children showed
significant reductions in psychiatric symptoms suggesting a clear family benefit associated with
mutual aid attendance – a key research finding in the context of Hidden Harm (ACMD, 2003) and
the Getting It Right For Every Child (GIRFEC) agenda.
7.6 Family and the recovery journey
The definition of ‘family’ is a very personal one. While it generally refers to blood relatives, many
people feel family ties with others as well and it is this broader context of family that is relevant to
the section below. However, improving family relations or renewing family bonds can be a key aim
for clients and it is essential that working towards resolution around family issues is prominent in
recovery oriented treatment.
The recovery approach is based on the assumption that the key elements of recovery take place in
the community and so the family is central to any attempts to generate recovery not least because of
the damage that the family is likely to have experienced during the periods of addiction. White (1990)
has argued that the family will need to undertake a recovery journey that may involve a range of
complex family relationships and individual pathways – including intimate relationships and parentchild relationships but also the other relationships in the family not involving the active addict.
Scottish Families Affected by Drugs is a national charity that exclusively supports families that are
affected by drugs. They agree with White (1990) that while families may have a role to play in
supporting someone’s recovery, they too may also need to ‘recover’. Although key workers’ main
focus will be the client with drug and/or alcohol problems, Lanarkshire ADP is also committed to
supporting families, including their children who are affected by alcohol and drugs problems.
Key workers should not assume that relationships with family is the root of the client’s issues with
drugs or alcohol and therefore questions should be posed about the relationships that a client has
with their family. It may be that their partner, mother or siblings are supportive and could prove an
essential recovery support for the client.
However, it is not uncommon for families to experience problems associated with a client’s recovery
journey. Recovery involves change and it may be that as the person changes, so this can cause
disruptions in the family. Frequent quarrelling, poor communication, blaming, distrust, and
unrealistic expectations are examples of family problems often described by recovering people.
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The starting point for this session with the client is outlined in Figure 43 below. This involves writing
down the names of family members who have been helpful in the recovery journey, what it is they
do and how the client manages unhelpful issues that come up with family members. Linked to the
discussion in the previous chapter on self-efficacy, some key questions for prompting completion of
this map could be:
“What have you tried to do that has helped the problem (even a little bit)?”
“What could you try that’s new or different to solve the problem?”
“What makes you think this might work?”
“What’s the first step you might take?”
“How will you know if it is working?”
Figure 43: Map 9.1 ‘Family support’
Who in your family
has been most
helpful in your
recovery journey?
What does he / she
do that helps your
recovery journey?
What do you do to
take care of yourself
when you deal with
unsupportive family
members?
At this point it is critical that you have a list of local family support groups and services that you can
give to the client and discuss their merits and suitability for them – but you must have some
knowledge of what each does and what they offer. Details of local family support groups are
available from Lanarkshire ADP website http://www.lanarkshireadp.org or from Scottish Families
Affected by Drugs - www.sfad.org.uk
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7.7 Communication skills
Communication plays a central role in our relationships. Often it’s not so much what we say as how
we say it that leads to problems. When we don’t send and receive clear messages, communication
breaks down, and this is what can leave us feeling frustrated, confused and angry. It might be useful
to think of a conversation as a series of messages sent and received between two people. A message
has a verbal part (words, expression, tone of voice) and a non-verbal part (gesture, eye contact,
posture). Communications can break down because we don’t send or receive clear messages but
they can also break down when we are under the influence of alcohol or drugs.
Exercise in using I-statements
Ask the client to think of the impact of these statements:
• You make me feel angry because you’re late
• I’m feeling angry because you’re late
• You’re lying
• I don’t believe what you’re saying
• You’re an inconsiderate slob
• I’d like you to be more considerate
In the above examples, using the I-statements can help improve communication and avoid
roadblocks. Roadblocks arise because we don’t explain things very well or because what is clear in
our heads does not come out that way. Also, we often assume that people know what we are feeling
but we do need to be able to articulate these thoughts and ideas to people. It is essential that the
client recognises the impact of their communication style and that the process of growing personal
warmth and a reflective style that is associated with sustainable recovery.
Another problem arises because listening is hard work and it is easy to get distracted by other
thoughts or demands, and often our own thoughts will disrupt our capacity to listen. Not listening is
perhaps the biggest roadblock of all. If we don’t listen we seldom understand what the other person
has said. This can lead to misunderstanding and confusion, and the speaker may feel insulted,
frustrated and angry. But we have all had the experience where we are talking about one thing and
the person we are talking about thinks we are talking about something else.
We need to understand that people won’t always understand what we are saying – so there is a
clear rule:
We all need to be patient and try not to get angry
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We need to look for signs that our messages are not being understood or have been taken in the
wrong way. Nobody is a mind reader and it is our responsibility to tell others what we are feeling.
They might not recognise the client’s recovery and it is important for key workers to emphasise the
need for clients to communicate what they need and want. The key steps are:
Improving our communication:
- What can you do to overcome the communication barrier?
- What can we do to express our feelings more clearly?
- How can I make sure that I listen more effectively?
Improving listening habits
The best way to improve listening habits is by practising. Key workers should encourage clients to
concentrate on what the other person is saying instead of their own thoughts and ideas. One of the
things to do is to stop interrupting others. Not listening to others is perhaps the biggest roadblock
of all – good communication depends on good listening. Even if we do listen, it is important that we
respond appropriately. It is not helpful to respond to other people’s ideas with anger or sarcasm.
This can be damaging especially in relationships with people we care about and particularly for
clients who may jeopardise important relationships that support their recovery journeys.
The next potential roadblock to communicating effectively is about being clear about saying no to
people. This is often the case because we feel that we are being pulled in two directions (we both
want to say ‘yes’ and ‘no’). There is a risk that we end up saying yes to things because we don’t
want others to think badly of us. Key workers should encourage clients to keep in mind that they
have the right to say ‘no’. Encourage them to develop their own style that they feel comfortable
with for saying no to people. Encourage them to ask for time to think about decisions when they are
feeling pressured into doing things.
Communicating well is hard work. It is helpful to become aware of the things that get in the way of
the client’s ability to communicate effectively and to learn skills for overcoming these barriers. It can
make a big difference in the recovery journey, with their partner and with family.
Many communication problems stem from poor listening and the best remedy is practice.
Look for opportunities in the client’s daily life to practice active listening.
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Figure 44: Map 9.2 ‘Communication roadblocks’
We assume that people know what we are talking about?
But they don’t always
Look for signs that what you are saying is not being understood
We assume that people know what we are feeling
Don’t count on it
Use ‘I’ statements to send a clear and honest message
We don’t listen very well
Listening is hard work!
It helps to concentrate on what the other person is saying instead of your own thoughts
and ideas
We sometimes overreact to what people say
Especially when we disagree
Listening doesn’t mean agreeing – stay calm – listen and respond using ‘I’ statements
to express your views
We are not always clear about saying ‘no’
Fence-sitting creates confusion
Ask for time to think when you need it. Avoid saying ‘yes’ when you want to say ‘no’
Assertive communication
Improving social skills and gaining confidence in our ability to communicate effectively has been
shown to enhance recovery and reduce the risk of setbacks. Good communication means being able
to share ideas, feelings, opinions, and plans with others in an open, non-defensive way that
enhances understanding and keeps the line of communication open.
Good communication is also about being able to listen to the ideas, opinions and feelings of others.
The ability to express ideas and listen to others is a skill. When people learn this skill and how to use
it, there is likely to be an improvement in relationships, self-esteem and the ability to manage
conflict.
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Many communication problems in relationships begin when one or both people involved in an
interaction feel hurt, angry or treated unfairly. It is important to be clear with the clients about
communication styles and the importance of developing effective and assertive communication.
This is based on the idea that assertiveness promotes equality and fairness in relationships and that
what you are trying to communicate to the world is that:
{
“I believe I am important
and I believe that you are
important too”
}
The key characteristics of the assertive style are:
• Talking in a clear, level tone of voice
• Using appropriate gestures and motions
• Maintaining good eye contact when you talk to someone
• Listening well; not interrupting when the other person is talking
• Speaking for yourself (using ‘I-statements’)
• Asking for what you want
• Controlling your temper when others are angry or rude
This approach is to be contrasted to the aggressive style which shuts down communication and
distances us from the people we are close to and causes others to withdraw from us which is likely
to have an adverse effect on self-esteem both in ourselves and in those we are speaking to! Similarly
we need to avoid the passive style, in which we fail to respect our own rights and which may leave
us open to manipulation or exploitation by others.
In most situations the assertive style is likely to be more effective than either the passive or
aggressive style. An assertive style keeps us focused on our feelings, goals and needs, and enhances
fair and equal relationships.
Assertiveness enhances relationships and increases closeness and intimacy with special people in
our lives. It also helps us establish new friendships, and gives us more confidence in groups or
new social situations.
Coping with the stresses of family life
Learning to manage stress and its discomforts is an important recovery issue. At one time or
another, almost everyone has felt overwhelmed by stresses and strains. The purpose of this section
is to focus on our own strengths and abilities for coping with stress. Our physical health plays an
important part in how well we deal with stress. One long-term strategy for dealing with stress is to
develop a personal plan for improving overall health. This includes nutrition, exercise, relaxation and
learning not to over-react to things we can’t control.
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The first task is to consider what has been causing the client most stress recently – focus in on
a clear mental picture of the stressful event or situation that is most troubling in their life. Once they
have done that, the next challenge is to help them to identify and reflect on what their most
important strength for dealing with stress is. Linked to this is the reflection on how the client
manages to pull through tough times. Use the map within Figure 45 to reflect on how to manage
the stressful experience.
Figure 45: Map 9.3 ‘Solutions to stress’
Current stressor:
1 2 3 4 5 6 7 8 9 10
If 1 represents no stress at all and 10 represents the worst, rate your stress today
What are you doing
to cope?
What has worked
in the past?
What is one thing you
could do to
lower your stress?
It is important to focus on strengths and abilities and what the client is currently doing that is
helping to deal with stress. The idea is not to eliminate stress completely but to learn to keep stress
at a manageable level so that they don’t feel overwhelmed and powerless. Their own coping is really
important but it is not the only thing. Sometimes life’s stresses are too difficult to handle alone and
drawing on the client’s social recovery resources will be potentially really important. Key workers
should encourage clients to talk with one of their support resources, either the key worker, a peer or
a supportive family member who can talk through the options and discuss what they can do.
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Managing anger in relationships
Anger is part of being human – the ability to feel anger is something we are all born with and it is a
personal right. All of us are entitled to our angry feelings. However, how we go about expressing our
anger is another matter. We are not entitled to express our anger in ways that violate other people’s
rights or feelings. When we choose to do so, we are responsible for the consequences.
Expressing anger in ways that destroys our relationships or threatens recovery is self-defeating – if
our anger is driving away the people we love or care about, cutting us off from our feelings, making
us feel guilty or closing recovery doors, it is time to consider some changes.
There are different degrees of anger such as frustration, disappointment, jealousy, being annoyed
and being irritated, and we each have unique ways of dealing with our anger. Once we are aware of
feeling angry, the next thing to do is to express this in a healthy way and then resolve it (and let it
go). It is not healthy to ‘swallow’ anger or let it go unresolved. When we swallow anger we may
begin to feel resentment or hostility. There is even some evidence that holding back anger causes
health problems such as stress or high blood pressure.
When we are expressing our anger, we have to decide whether we are going to respect the rights of
others or stamp on them. Examples of stepping on the rights of others include yelling, using threats or
using violence, or we can do this by shutting down emotionally. If we usually ignore the rights of others
when we express anger, it can lead to relationship problems and problems with getting on with your
life. Using I-statements, you can learn to discuss the reasons for your anger and to ask for change.
Letting off steam may also help you to calm down. When we are calm it is much easier to solve
problems and to be open to new solutions. Some people find it helpful to take a shower, go for a
walk or even to talk to a third party about the problem. Finding ways to ‘vent the steam’ without
intimidating or hurting others is a useful approach.
Listening to others is an important way of resolving anger and letting it go. Trying to understand
the other person’s point of view will usually help you reach a resolution that both of you can
live with.
Forgiving involves being able to accept apologies when they are offered and working to bring
relationships back to their non-angry state. It also involves letting things go instead of ‘saving them
up’ for the next disagreement.
Some key issues that key workers might want to encourage clients to reflect upon or discuss with
them, a peer or family member or if they are a member of a group, include:
- What do you want to change about how you deal with anger?
- How are you different when you are not angry?
- When you change how you deal with your anger, how will your life be different?
- What is one thing you can try next week to work on your goal?
Complete the anger map in Figure 46 to summarise where the client is with this process.
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Figure 46: Map 9.4 ‘Managing anger’
Ways to
express your
anger
Stepping on the rights of others
Respecting the rights of others
Shouting, threats, violence,
blaming
‘I’ statements, asking for change,
listening, resolving, working to
achieve a ‘win-win’ situation
Relationship problems, work
problems, little support
Better relationships, effectiveness
at work, more support
7.8 Recovery and the future
At some point in life, clients will have to sustain the changes they have made on their own and that
will be away from the formal treatment setting. Key workers should emphasise that this doesn’t
mean that they are on their own and that they don’t have any supports. As well as structured
groups like 12-step and SMART, this is the time for clients to reflect on the growth of their personal
and social capital – the reserves they will have built up that collectively constitute their recovery
growth and capital. A starting point for this discussion is for clients to think – on a scale from 1 to 10
– where 1 is where they were when they started treatment and 10 is where they want to be:
Where would you say you are today?
The changes they have made in their life to date, and the changes that they will continue to make
involve lots of hard work. The goals that they have set for themselves for recovery are not simple
goals to achieve. They deserve recognition and respect for their willingness to tackle their problems
and to try to solve them. Key workers should encourage clients to stop regularly and reflect on what
they have achieved and where they now think they are. This is also the time to think about the
challenges that lie ahead and things that might get in the way of the progress they are making.
It is helpful to anticipate possible difficulties and to think about creative ways of handling those
situations should they arise.
Setbacks are possible at all stages of recovery. When setbacks happen, it is important for key
workers to help clients avoid burdening themselves with feelings of guilt, shame, or hopelessness.
These negative feelings may be more detrimental to recovery than the slips themselves. Setbacks
are not a mark of failure – they are just part of being human.
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There are a few things clients can do:
• Talk it out with someone
• Don’t beat themselves up
• Think of each setback as a gentle reminder that they need to think about what they could do
differently – and what the setback teaches them about themselves.
The mapping approach does not become irrelevant and at these points it might be useful to arm the
client with recovery maps that they can use as part of their recovery journey in the community as
outlined in Figure 47.
Figure 47: Map 10.1 ‘Recovery goals’
Goal:
How will things be
different when you
reach this goal?
What do you need to
begin working on this
goal? What steps make
sense?
What are three of your
positive personality
strengths that will help
you reach this goal?
1.
2.
3.
How will you review and reflect on achieving this goal?
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The map is again focused on asking the client to recognise and then mobilise their strengths as part
of the recovery process. The key part of this process is about encouraging clients to think in the
longer term and to plan beyond immediate goals to longer-term aspects of their recovery journey.
Similarly, the path to recovery will not be a simple or clear one for many people and one of the main
tasks is to address the problems that arise, as shown in Figure 48.
Figure 48: Map 10.2 ‘Managing concerns’
What do you see as your primary concern?
What are some steps to take?
How will this help?
7.9 Community recovery capital
Building community capital or linking clients to helpful people in their community that can support
them is an essential component part of recovery. A key starting point is the list of skills and
resources that exist in the individuals, associations and institutions that already exist in the recovery
populations.
Because of the variety of personal journeys to recovery and the resultant diversity of pathways and
supports, at a systems level, the aim is to encourage communities to develop a diverse array of the
kinds of recovery groups outlined previously and to have this as a vibrant and active part of the local
community. One of the most exciting things about recovery is that it can help not only people in
recovery from addictions but also their families and their communities. In exactly the same way that
addiction can blight communities although the substances are only used by the individuals, so
recovery can transform those same communities, families and recovery groups, making them
become a positive force for all in those areas.
While many people in recovery want to ‘give something back’ by training to be drug workers and
counsellors, there are many things that can be done through volunteering and community
engagement including supporting neighbours, the disabled and those with other problems and to do
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so by the power of collective activities and plans. There will be a huge array of social activities and
issues in the community that key workers and people in recovery can become involved in and
contribute to.
This form of community engagement has two main consequences. Firstly, it creates a visible
presence and identity for recovery and a focal point for community engagement. Secondly, it is a
way of challenging discrimination in local areas. Many people want to move away from the area and
preserve their anonymity as part of their recovery process and one of the core messages here is to
celebrate and encourage the full diversity of recovery experiences. However, for those who have the
supports and strengths, their own recovery can provide a message of hope to others still in active
addiction and can challenge lazy stereotypes and beliefs about addicts in those communities.
In the areas where recovery groups have high visibility and take part in a diversity of local
community activities, it is a constant reminder that recovery is a force for good that ripples out from
the person and into their community.
Figure 49: Map 10.3 ‘Changing your community’
What could you do?
Who else could you
get to help?
Challenges?
What would you like
to change in your
community?
For the client, developing their interests and passions is a core part of their recovery journey and
discovering new talents and skills is a major part of that celebration of recovery. Some of those
things may be things they want to do by themselves – and this may apply to lots of their recovery
progress – but there is a lot of evidence that would suggest that doing things with peers – especially
peers in recovery – can help. That means not only focusing on recovery activities but also indulging
those interests and passions that are part of the essential recovery growth experience. Clients will
also want to build on them and to celebrate their successes and growth away from substances.
It is important that they record such success and celebrate it with other people. Key workers are
encouraged to use the map within Figure 50 to reflect, with the client, about what has gone right
and to build on those successes and to keep them in mind. In part, this is about the client
recognising how far they have come but it is also important as a way of working out what skills they
have (and are continuing to grow) and the specific things they have done to build on success.
These are the strengths that will allow them to challenge themselves more as they progress in their
recovery journey and are the building blocks of the recovery capital that are part of that ongoing
process. The map is essentially about celebrating successes and building upon these.
98
Figure 50: Map 10.4 ‘Building on success’
What was your success?
How did you make it happen?
What did you do to
make it happen?
How did you decide
what might work?
What did
you learn?
How can you use what you’ve learned from this in the future?
99
The map within Figure 51 is one that key workers will recognise as it is the basic planning map from
the recovery plans but at this stage, clients should now be able to approach this with a different sets
of strengths and supports that will allow them to tackle much bigger challenges and to see
themselves much more clearly as someone who can make things happen and move things forward.
But building on this future also relies on the client having a clear vision of where they want to go
and Figure 51 is a part of that process of having some clear goals. Although many people will see
recovery as something that does not have an end point, the client may still have some specific
objectives they want to reach.
Figure 51: Map 10.5 ‘Looking forward’
Friends?
Family?
Living situation?
What do you
see when you
picture the
future you want
for yourself?
What do all of these things have in common?
100
Work / job?
7.10 Recovery plan reviews
As part of the general ethos of building on success and accentuating the positive, the first task in
the review process is to identify successes and to get the clients to reflect on them. Figure 52 below
provides a map that is designed to assist in this process and is about the client recognising their own
achievements and using that success to build more general learning principles and to reflect on the
processes underlying their success.
Figure 52: Map 10.6 ‘Recovery plan review’
A problem I have
Progress I have
made in tackling
this problem
What has still
to be done?
101
The key worker has the opportunity to help the client reflect on their learning and on the steps and
strategies that they have used both to build esteem and to enable strategies and planning to be
structured and put into action. However, not everything that is tried will succeed and there is much
to be learned from failure as well as from success, and especially to see failures as temporary
roadblocks or diversions in the longer term recovery journey. At the opposite end of the spectrum is
identifying and dealing with things that were not successful.
The aim is to revise and refresh the earlier recovery plan, using four main sources:
1. The most recent previous recovery plan
2. The person’s own reflections on their current needs
3. The key areas of strength identified in the Assessment of Recovery Capital (ARC)
4. The therapeutic issues raised by the Client Evaluation of Self in Treatment (CEST)
To do this, it is essential that the recovery plan is a living document (not simply something that is
filled in for auditing purposes), but a record for both the client and the key worker about what the
tasks are. It is essential to recognise that each review and recovery plan involves mapping the
resources that can be employed. Here we will draw on the work of Kretzmann and McKnight in the
Asset-Based Community Development model (Kretzmann and McKnight, 1993), and his suggestion
that the resources available to the key worker and client will often exist in the community in:
- The individual’s own assets and strengths
- Their family and peer group
- The recovery community in the area
- Other key associations and groups that the person can be tapped into in the community
- The organisations and institutions in the area that can help
For the last three of these, the key worker and the service must have a good and up-to-date
knowledge of local community and mutual aid groups. For this reason we have been developing the
role of “therapeutic champions” within our local services. Our therapeutic champions have agreed
to take responsibility for maintaining and updating personal links and a directory that all staff have
access to, that will provide information about what is going on in their local communities and who
the key link people are.
102
Chapter 8
Conclusion
This manual is part of an ongoing growth of interest in the science and practice of recovery thinking
in United Kingdom and so is not in any sense definitive or complete. What we have attempted to do
here is to bring together two crucial strands of work:
1. The therapeutic and organisational innovation from the Institute of Behavioural Research
(IBR) at Texan Christian University (TCU), building on a strong evidence base developed over
many years. This work has shaped thinking internationally on the implementation of
evidence-based practice in routine clinical settings using a technique called node-link
mapping, and that is the cornerstone for the approach outlined in the manual
2. The growing evidence base about the effectiveness of ‘recovery’ approaches based on the
idea that broad principles of hope, empowerment, community engagement and selfdetermination are at the heart of the long-term process of overcoming addictive behaviours.
So what is presented in the manual is a first attempt to link these two activities and approaches to
help key workers and clients derive more benefit from the exchanges that take place in formal
clinical settings and then to improve the transition of recovery focus to the family and the
community. This is a hugely ambitious undertaking and this is a first attempt – whose aims are to
assist in the empowerment of key workers and people undertaking recovery journeys. Broadly, the
aim is to instil hope and generate shared aspirations and more narrowly to offer some suggestions
and techniques that can support and sustain those efforts.
We have been extremely fortunate that a number of colleagues and friends who are both in recovery
and experienced clinicians have offered their thoughts and suggestions. There are things here that
will improve with testing and application and from input from key workers and clients alike.
The structured and information maps should be supplemented by many maps that are designed for
use in specific working settings and the structured maps can be amended and replaced by things
that are more useful in local contexts. And it is of course our hope that as recovery guides and key
workers develop confidence with the approach and the techniques of node-link mapping, free maps
will become a central part of the repertoire of this approach.
This is an exciting time in Scotland in terms of new thinking and an openness to new approaches
and methods and the recovery movement is shifting how we see key aspects of addiction and
recovery, the role of key workers and the role of communities, families and peers in supporting
individuals in their recovery journey. So there may never be definitive guidance, and it is crucial that
what is here is a stepping stone to linking the achievements of recovery with the lessons from the
treatment effectiveness world of academics and clinicians.
103
So we hope you will use the maps and occasionally consult with this manual but be kind and gentle
– it is only a guide map itself that you have to use and interpret for the personal recovery story of
each client you work with. Recovery will always be a personal and idiosyncratic process of discovery
and empowerment and this approach, like many others, can do no more than help. What it can help
however, is communication and the way that key workers, peers, recovery champions and supports
from their family and community members can support clients and their family in recovery.
Good luck and please remember that the techniques are much less important than the principles of
respect, hope, choice, empowerment, sharing and belief.
David Best
January 2011
©2010 University of the West of Scotland
104
Chapter 9
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Appendix 1
Book of maps
Phase 1: Engagement and motivation
1.1 My drug use
1.2 Problems with my drug use
1.3 Weighing it up
1.4 What’s important to me?
1.5 My tower of strengths
1.6 Planning for change
2.1 My strengths
2.2 Me today
2.3 Basic needs
2.4 Goal planner
2.5 Recovery plan
2.6 Making changes
Phase 2: Building recovery capital/psychosocial change
3.1 High and low self-esteem
3.2 Effects of low self-esteem
3.3 Building your self-esteem
3.4 Improving self-esteem
4.1 Identifying the blocks
4.2 Building skills and strengths
5.1 A positive identity
5.2 Recovery principles
5.3 Recovery identity
109
Phase 3: Recovery and re-engagement/re integration
and recovery
6.1 What is recovery?
6.2 Defining recovery
6.3 Identifying a recovery network
6.4 Recovery guides
6.5 Overcoming barriers: Engagement with 12 step groups
6.6 Sobriety networks
7.1 Planning a recovery day
7.2 Recovery journal
7.3 Improving wellbeing
7.4 Health checklist
8.1 Building your recovery assets
8.2 Exploring recovery assets
8.3 Mutual aid groups
9.1 Family support
9.2 Communication roadblocks
9.3 Solutions to stress
9.4 Managing anger
10.1 Recovery goals
10.2 Managing concerns
10.3 Changing your community
10.4 Building on success
10.5 Looking forward
10.6 Recovery plan review
110
Map 1.1
My drug use
Drug:
Things that are good about using
Things that aren’t so good about using
Completing this list will help you prepare for the next map.
111
Map 1.2
Problems with my drug use
What difficulties have you had
with your drug use?
What makes you think
this is a problem?
Example: you often think about stopping
My use of
In what ways have you or others been
harmed by your drug use?
How has your drug use stopped
you doing what you want to do?
112
Map 1.3
Weighing it up
Continuing to use as before
Advantages
Disadvantages
Making a change to my use
Advantages
Disadvantages
What change could you make to your drinking or drug use?
Look back at this map when you are ready to plan what actions you are going to take.
113
Map 1.4
What’s important to me?
Places
People
Example: partner, children
Activities
Example: work, football
Things / Objects
Example: clothes, iPod
Example: my house
Things
that are
important
to me
in life
Feelings / Emotions
Example: happiness
Can you think of anything else?
Example: future goals
Now you have resolved to take action to change your substance use, the next set of
maps will help you to plan what action to take and how to assess your progress.
114
Map 1.5
My tower of strengths
Strengths I would like to work on developing and supports I need
My strengths
E.g I am motivated
Supports from other people
E.g A supportive person
Strengths I know I have to help me deal with my problems
115
Map 1.6
Planning for change
1. The change I want to make:
2. The reason why I want to
make this change:
4. The first steps I will take:
3. My main goals for
achieving this change:
What:
5. People who could help me:
6. The positive results that I
hope my plan will have:
What they could do:
When:
116
Map 2.1
My strengths
Health and physical
Where I live
Social relationships
Example: my partner
What are
your strengths?
Values and beliefs
Emotions /
Coping skills
Example: strong willed, calm
Work and skills
Example: motivation and
commitment to change
Example: worked in a shop
117
Map 2.2
Me today
Health
Interests
Relationships
Me today
Emotions
Work
Housing
118
Map 2.3
Basic needs
Treatment efforts to date
Severity of substance use
Emotions / temperament
Education, work, offending history
Current
Problems
and
Resources
Housing and basic needs
Major strengths
Social support, family
Possible challenges
119
Map 2.4
Goal planner
Problem
area
Satisfaction out
of 10
What would have to change to
score 10 out of 10?
Priority
Drug and / or
alcohol use
Health (physical
and mental)
Social life
and friends
Relationships
Housing
Job / Education
Money
Exercise
Legal and crime
You can add extra priorities or problem areas if there are others for you.
120
Map 2.5
Recovery plan
Priority
area
E.g Poor housing
Describe the
problem
Living in flats
surrounded by
people using
drink/drugs
Goal for tackling
the problem
Make appointment with
housing officer
Date to
achieve
Tomorrow
121
Map 2.6
Making changes
Specific actions
When
My goal
Helpful people & thoughts
Strengths
Possible problems
Solutions
Now look at each of your goals and decide which one you intend to start with.
122
Map 3.1
High and low self-esteem
Joanne, is on a DTTO.
She’s started college to retake her
Higher Maths. She has just taken her
Maths prelim. She got an F and
she’d hoped she’d get a C.
If Joanne has HIGH self-esteem,
what might she say to herself
when she receives her F grade?
If Joanne has LOW self-esteem,
what might she say to herself
when she receives her F grade?
Adrian, has been looking for a job.
He gets a letter inviting him to a job interview.
Adrian wants the job but gets
nervous in interviews.
If Adrian has HIGH self-esteem,
what might he say to himself
once his read the letter?
If Adrian has LOW self-esteem,
what might he say to himself
once his read the letter?
123
Map 3.2
Effects of low self-esteem
Suzi’s situation:
Suzi’s thoughts:
Effect on Suzi’s life:
Peter’s thoughts:
Effect on Peter’s life:
Joanne’s thoughts:
Effect on Joanne’s life:
Alison’s thoughts:
Effect on Alison’s life:
A friend has helped Suzi
find a new job as a
receptionist but Suzi
thinks she won’t be able
to manage the work.
Peter’s situation:
Peter and Julie have
been seeing each other
for 4 months. Peter
really likes Julie but
can’t understand why
she likes him.
Joanne’s situation:
Joanne is disappointed
that she got an F grade
for her maths test.
Alison’s situation:
Alison has been taking
driving lessons so that she
can legally drive. Her
instructor thinks she
should put in for her test
but Alison is afraid of
failing.
124
Map 3.3
Building your self-esteem
Negative message
Challenging message
Makes generalizations:
“I didn’t get the job I went for. I’ll
never get a job, I don’t have anything
to offer.”
Is specific:
“I wanted that job and I didn’t get it
but that doesn’t mean that I’ll never
get a job, I’ve got jobs before, so I know
that I’m employable.”
Makes small upsets into big problems:
“He doesn’t like the CD I bought him. He
must think I have awful taste. I never
give good presents, I’m such a bad
friend.”
Looks at things realistically:
“I’m disappointed that he doesn’t like
the CD but he usually likes the stuff I
get him.”
Makes illogical leaps:
“She’s looking at me funny. It’s ‘cos she
knows I use. She thinks she’s better
than me. ”
Challenges illogical thoughts:
“Yeah, she is pulling a face, but I don’t
know why. She might be having a bad
day, that doesn’t mean she’s looking
down on me.”
Is too harsh:
“My tutor said that my work was
good, but I think it should have been
better. I can’t see how they didn’t
notice how much was wrong with it.”
Be reassuring:
“My work was good. It might not
have been perfect but I’m still learning
and I did a good job. I should be proud
of myself.”
Negative messages you use:
How you can challenge this:
125
Map 3.4
Improving self-esteem
Ways I can look after myself:
Things I can say to challenge
my negative self talk:
What are my strengths and
achievements?
Who can I talk to
for support?
Things
I can do to
improve my
self-esteem
Things I can do to treat myself
when I’m feeling down:
126
Map 4.1
Identifying the blocks
Goal being blocked:
Who can be recruited
to help?
Can it be broken
down into tasks?
What is
the block to
achieving the goal?
What are the skills
required and what strengths
do you have?
What can you learn
from this?
How have you achieved
similar things?
Alternatives to my problem are...
127
Map 4.2
Building skills and strengths
Your aim:
Possible choices you
can make:
Consequences
of choice:
Resources you can
draw upon:
Strengths you
possess:
Barriers:
Deciding on your strategy
Implementing your plan
and reflecting on what
you can learn about
your strengths and
resources
Which choice
seems best?
Negative
Consequences of choices
Positive
128
Map 5.1
A positive identity
Quality I would
like to have
My rating
(1-10)
Sense of calm
7
An example of
how I display this
quality now
I did not get upset or angry
when my partner came
home late last night.
How can this
help you in
your recovery?
I can cope with
angry, upset or
difficult feelings.
129
Map 5.2
Recovery principles
What are your internal recovery strengths?
What are the things that inspire you?
What recovery values do you hold?
What successes can you build on?
What can your recovery guides do to help?
What gives you hope?
130
Map 5.3
Recovery identity
What are the bad
things about using you
are leaving behind?
What are the good
things about recovery?
What new doors does
this open for you?
How has it changed how you see yourself?
And what else do you need to grow your recovery self?
131
Map 6.1
What is recovery?
Spend more time
with people who
don’t use
Learn new
skills
Be open to
new ideas
Do what works to
avoid cravings
Ask for
support when
you need it
Develop drug
free recovery
networks
Resolve anger, guilt
and frustration
about past drug use
Not using
– no matter what
Find new and
enjoyable social
activities
without drug
Get involved: job,
school, hobby,
pastime
Change attitudes
about drugs and
drug users
What does recovery mean for you?
As your recovery journey progresses, so may your aims and goals. You can come back
to this map and look at how your recovery goals change if you need to.
132
Map 6.2
Enabling recovery
How will you stop using all drugs and stop being around drugs?
How can you avoid people and situations that trigger your desire to use?
Can you ask a non-using family member or close friend
to be your ‘partner’ in recovery?
How will you go about forming a self-image of
yourself as a Person in Recovery?
What can you do to plan your time and stay busy?
133
Map 6.3
Identifying a recovery network
Who do you know who is in recovery?
What recovery activities do you
engage in with them?
How do they help
your recovery
How could they link you to
recovery groups?
What could you do to engage
with others in recovery?
How could you help their recovery journeys?
134
Map 6.4
Recovery guides
What can you learn
from them?
What supports can
they provide?
Who is the
person you know
who has made
most recovery
progress?
What do they do
that you could do?
What are the challenges you
face to get what they have?
135
Overcoming barriers:
Engagement with 12 step groups
Map 6.5
What are the groups in
your area?
Where would you get info?
Who do you know who attends?
How would you find
someone to go with?
What are the barriers
to you attending
136
Map 6.6
Sobriety networks
Who do know who is clean and sober?
When can you next see them?
What can you do with them?
How can you get them to
help your recovery
What keeps them
clean and sober?
What can you learn and talk to them about?
137
Map 7.1
Planning a recovery day
What is the first step?
What strengths can you use?
What challenges
will you face?
Who can you rely on today?
What can they do?
What rewards will this bring?
138
Map 7.2
Recovery journal
Week beginning -
Recovery
area
Success
Rough spots
Concerns
Goals
Staying clean
Recovery work
Social
relationships
Personal
139
Map 7.3
Improving wellbeing
140
Map 7.4
Health checklist
My goal is:
First step:
My goal is:
First step:
My goal is:
First step:
My goal is:
First step:
Sleep
Nutrition
Exercise
Having
fun
Try to think about how to link these things into your daily routines
and make them part of your emerging recovery rituals.
141
Map 8.1
Building your recovery assets
Who are your
assets?
What is good
about them?
What benefits
do they offer
you?
How can they
be a part of
your recovery
journey?
You
Family
Friends
Recovery Groups
Community
Groups
Workers
Peers
Others
142
Map 8.2
Exploring recovery assets
What aspects of your
recovery can they build?
For each
recovery
asset
What can you do to make
the most of this asset?
What are the opportunities
you have with them?
143
Map 8.3
Mutual aid groups
What other
types of
groups do
you need as
well?
Shop
around –
what do you
want?
What are your
‘warning signs’
that you
should attend?
Engaging
with
mutual aid
Are the times
right for you?
Do you have
someone to
go with?
Prepare so
that you can
attend at
least weekly
Do you
need a
mentor or
sponsor?
144
Map 9.1
Family support
Who in your family has
been most helpful in your
recovery journey?
What does he / she do
that helps your
recovery journey?
What do you do to take
care of yourself when you
deal with unsupportive
family members?
145
Map 9.2
Communication roadblocks
We assume that people know what we are talking about?
But they don’t always
Look for signs that what you are saying is not being understood
We assume that people know what we are feeling
Don’t count on it
Use ‘I’ statements to send a clear and honest message
We don’t listen very well
Listening is hard work!
It helps to concentrate on what the other person is saying instead of your own
thoughts and ideas
We sometimes overreact to what people say
Especially when we disagree
Listening doesn’t mean agreeing – stay calm – listen and respond using ‘I’
statements to express your views
We are not always clear about saying ‘no’
Fence-sitting creates confusion
Ask for time to think when you need it. Avoid saying ‘yes’ when you want to say ‘no’
146
Map 9.3
Solutions to stress
Current stressor:
1 2 3 4 5 6 7 8 9 10
If 1 represents no stress at all and 10 represents the worst, rate your stress today
What are you doing
to cope?
What has worked
in the past?
What is one thing
you could do to
lower your stress?
147
Map 9.4
Managing anger
Ways to
express
your anger
Stepping on the rights
of others
Respecting the rights of others
Shouting, threats, violence,
blaming
‘I’ statements, asking for change,
listening, resolving, working to
achieve a ‘win-win’ situation
Relationship problems, work
problems, little support
Better relationships,
effectiveness at work, more
support
148
Map 10.1
Recovery goals
Goal:
How will things be
different when you
reach this goal?
What do you need to
begin working on this
goal? What steps make
sense?
What are three of your
positive personality
strengths that will help
you reach this goal?
1.
2.
3.
How will you review and reflect on achieving this goal?
149
Map 10.2
Managing concerns
What do you see as your primary concern?
What are some steps to take?
How will this help?
150
Map 10.3
Changing your community
What could you do?
Challenges?
Who else could you
get to help?
What would you like to
change in your community?
151
Map 10.4
Building on success
What was your success?
How did you make it happen?
What did you do
to make it happen?
How did you decide
what might work?
What did you learn?
How can you use what you’ve learned from this in the future?
152
Map 10.5
Looking forward
Friends?
Family?
Living situation?
What do you
see when you
picture the
future you want
for yourself?
Work / job?
What do all of these things have in common?
153
Map 10.6
Recovery plan review
A problem I have
Progress I have made in
tackling this problem
What has still
to be done?
154
Appendix 2
Client Evaluation of Self and Treatment (CEST)
Client Evaluation of Self and Treatment
Please tick if you agree with any of the following statements
1. It is urgent that you find help immediately for your drug use
2. You trust your key worker
3. Time schedules for treatment sessions at this service are convenient for you
4. You are in this treatment program because someone else made you come
5. It's always easy to follow or understand what your keyworker is trying to tell you
6. This service expects you to learn responsibility and self-discipline
7. Your keyworker is easy to talk to
8. You are willing to talk about your feelings during treatment
9. You will give up your friends and hangouts to solve your drug problems
10. This service is organised and run well
11. You are motivated and encouraged by your keyworker
12. You are tired of the problems caused by drugs
13. You have too many outside responsibilities now to be in this treatment program
14. You have made progress with your drug/alcohol problems
15. You are satisfied with this service
16. You want to get your life straightened out
17. You always attend the treatment sessions scheduled for you
18. This kind of treatment program will not be very helpful to you
19. You have made progress towards your treatment goals
20. Your life has gone out of control
21. Your keyworker recognises the progress you make in treatment
Continued...
155
22. You want to be in a drug treatment program now
23. Your keyworker is well organised and prepared for each treatment session
24. You plan to stay in this treatment program for a while
25. Your keyworker is sensitive to your situation and problems
26. This treatment may be your last chance to solve your drug problems
27. Your keyworker makes you feel foolish or ashamed
28. You have made progress in understanding your feelings and behaviour
29. You have stopped or greatly reduced your drug use while in this service
30. Your keyworker helps you develop confidence in yourself
31. This treatment program can really help you
32. You always participate actively in your treatment sessions
33. Your keyworker views your problems and situations realistically
34. You have improved your relationships with other people because of this treatment
35. The staff here are efficient at doing their jobs
36. This treatment program seems too demanding for you
37. You have made progress with your emotional or psychological issues
38. Your keyworker respects you and your opinions
39. You have learned to analyse and plan ways to solve your problems
40. You give honest feedback during treatment
41. You can depend on your keyworker's understanding
42. You can get plenty of one-to-one sessions at this service
43. This service location is convenient for you
44. You need help in dealing with your drug use
45. You are following your keyworker's guidance
46. Your treatment plan has reasonable objectives
156
In the Texan Christian University (TCU), the key instrument that is used is the Client Evaluation of
Self and Treatment (CEST, Joe et al 2002). This measures four domains of client functioning:
• Motivation to change
• Psychological functioning
• Social functioning
• Treatment engagement
In each of these domains, a series of scales is used, rated between 10 and 50 to identify the client’s
level of functioning in that area. In the Recovery Model presented here the middle two areas – of
psychological and social functioning – are measured using the Assessment of Recovery Capital – and
so the focus is on assessing Motivation and Treatment Engagement (the 1st Phase of the Treatment
Process Model). The premise from the TPM is the same however, clients who are poorly motivated
are less likely to be able to make significant changes in their recovery functioning. In this sense
motivation means two things –
1 Motivation to move towards recovery
2 Therapeutic and treatment motivation
Recovery group
capital
Phase 3
5
4
3
Treatment
engagement
2
5
4
3
2
1
2
3
4
5
2
1
1
Phase 1
Treatment
motivation
1
3
4
5
Social
recovery
capital
1
2
3
4
5
Personal
recovery
capital
Phase 2
Figure A: The Stage Process of the Assessment of Recovery Capital Star (ARCS)
Thus the TCU scales for motivation and engagement are used in the model as the basic assessment
of Phase 1 of the Treatment Process Model (TPM). Here the assumption is that clients who are low
in motivation and poorly engaged with the service and the worker are less likely to make significant
changes in their recovery journeys. In contrast, a client who has positive aspirations to change and
who is effectively engaged in a strong therapeutic relationship within a treatment service has both
the motivational and the therapeutic capital to start on a recovery journey in treatment.
157
There are five scales that are used in this part of the assessment:
• Desire for help
• Treatment readiness
• Treatment satisfaction
• Key worker rapport
• Treatment participation
The second aspect of the treatment relationship relevant here is therapeutic capital which assesses
the client’s active engagement in the treatment process and the extent to which they see their
relationship with a worker (assessed in ‘keyworker rapport’) as a primary component of their
expectancy about recovery and their belief that treatment can enable this goal.
In total, there are 46 questions in this part of the assessment and these have been shown in a
number of studies to be linked to how well clients are engaged in treatment and how motivated they
are to change. So the first part of the process of assessment is to look at the total scores on
motivation and engagement as the way of shaping whether the treatment sessions and activities
should focus on motivation and engagement. The techniques to support this are laid out in Chapter 5.
It is important to recognise that the stage process of the Assessment of Recovery Capital Star is
sequential and that the therapeutic component of developing recovery capital rests on
motivation and engagement – in other words, this should be addressed – and intermittently
reviewed – as the basis for all other types of change.
158
Appendix 3
Assessment of Recovery Capital (ARC)
Assessment of Recovery Capital
Please tick if you agree with any of the following statements
1. Having a sense of purpose in life is important to my recovery journey
2. I am able to concentrate when I need to
3. I am actively involved in leisure and sport activities
4. I am coping with the stresses in my life
5. I am currently completely sober
6. I am free from worries about money
7. I am actively engaged in efforts to improve myself
(training, education and/or self-awareness)
8. I am happy dealing with a range of professional people
9. I am happy with my personal life
10. I am making good progress on my recovery journey
11. I am proud of my home
12. I am proud of the community I live in and feel a part of it
13. I am satisfied with my involvement with my family
14. I cope well with everyday tasks
15. I do not let other people down
16. I am free of threat or harm when I am at home
17. I am happy with my appearance
18. I engage in activities and events that support my recovery
19. I eat regularly and have a balanced diet
20. I engage in activities that I find enjoyable and fulfilling
21. I feel physically well enough to work
22. I feel safe and protected where I live
Continued...
159
23. I feel that I am in control of my substance use
24. I feel that I am free to shape my own destiny
25. I get lots of support from friends
26. I get the emotional help and support I need from my family
27. I have a special person that I can share my joys and sorrows with
28. I have access to opportunities for career development
(job opportunities, volunteering or apprenticeships)
29. I have enough energy to complete the tasks I set myself
30. I have had no ‘near things’ about relapsing
31. I have had no recent periods of substance intoxication
32. I have no problems getting around
33. I have the personal resources I need to make decisions about my future
34. I have the privacy I need
35. I look after my health and wellbeing
36. I make sure I do nothing that hurts or damages other people
37. I meet all my obligations promptly
38. I regard my life as challenging and fulfilling without the needs
for using drugs or alcohol
39. I sleep well most nights
40. I take full responsibility for my actions
41. It is important for me to contribute to society and/or be involved in activities
that contribute to my community
42. In general I am satisfied with my life
43. It is important for me to do what I can to help other people
44. It is important to me that I make a contribution to society
45. My living space has helped to drive my recovery journey
46. My personal identity does not revolve around drug use or drinking
47. There are more important things to me in life than using substances
48. What happens to me in the future mostly depends on me
49. I have a network of people I can rely on to support my recovery
50. When I think of the future I feel optimistic
160
The Assessment of Recovery Capital (ARC)
One of the new measures that will be utilised is a measure of strengths as well as the traditional
weakness areas – called the Assessment of Recovery Capital (ARC). As shown in Figure A below,
this is a tool that assesses strength scores in each of ten dimensions of client functioning. The chart
provides average scores from two community rehabilitation centres in the UK showing the extent of
strengths in the 10 areas of recovery growth
Figure A: Recovery strengths in the 10 domains of the Assessment of Recovery Capital (ARC)
2
4.22
4.44
2.91
3.35
3.44
3.71
2.95
3.51
2.55
3.38
2.78
2.78
3.5
3.89
3.1
3.48
3.66
3.41
3
4
4
4.33
5
Oaktrees
Recovery experience
Coping and life functioning
Risk taking
Housing and safety
Meaningful activities
Social support
Community involvement
Physical health
Psychological health
0
Substance use
and sobriety
1
LEAP
The ten domains split between ‘personal’ recovery and ‘social and lifestyle’ recovery factors as
shown in Table A below:
Table A: ARC domains grouped into areas of recovery capital
Personal recovery domains
Social and lifestyle recovery domains
Psychological health
Substance use and sobriety
Physical health
Community involvement
Risk taking
Social support
Life skills and functioning
Housing and safety
Recovery capital
Meaningful activities
161
Thus the Assessment of Recovery Capital (ARC) strength domain provides a self reported indicator
of the basic dimensions of personal and social recovery capital. Because this measures only
strengths it can be used alongside other assessment measures that assess acute risks and problems,
as are typically measured in assessment and review documents. This is a map of the strengths the
individual brings to the therapeutic relationship and should be used in conjunction with a treatment
approach predicated on strengths and solutions. However the overall model would suggest that
this should be linked to three other areas of strength and recovery capital for those engaged in the
treatment process:1. Motivation to change and to engage with recovery support
2. Strengths drawn from the therapeutic alliance
3. Strengths drawn from engagement in recovery groups
While the ARC assesses personal and social aspects of recovery capital, it does not assess the
strengths that can be drawn from engagement in recovery groups, and the final measure, the
Recovery Group Participation Scale (White, Groshkova and Best, 2011) attempts to address this.
162
Appendix 4
Recovery Group Participation Scale (RGPS)
Recovery Group Participation Scale (RGPS)
Please tick if you agree with any of the following statements
1. I attend recovery group meetings on a weekly basis or more frequently
2. If I did not make a meeting at my group for two weeks,
people would call to see if I was okay
3. I speak at recovery meetings
4. I perform service at recovery meetings
5. I carry a message of hope to others
6. I socialise before and / or after meetings
7. I attend recovery social events
8. I visit a recovery centre or cafe
9. I read recovery supportive literature
10. I carry a recovery object
11. I have people from my recovery group who support my recovery
12. I use daily recovery rituals
13. I do voluntary service to help my recovery group
14. I encourage others to attend my recovery group
The Recovery Group Participation Scale (RGPS) has been developed to measure engagement in any
type of recovery group, and is not focused exclusively on 12-step fellowships. In other words, it will
include not only other group activities like SMART Recovery but also groups whose focus is interestbased, vocational or housing based. It is a single scale where each item measures some aspect of
recovery group engagement that represents a core part of recovery capital.
163
Appendix 5
Linking the Treatment Process Model to Evidence
Based Psychosocial Interventions (HEAT A11)
The Treatment Process Model incorporates many evidenced based psychosocial interventions.
The table below represents where they are located within the Staff manual. This can also be used to
indicate where it may be helpful to focus further work and to undertake a structured, psychosocial
intervention. The areas highlighted by a * link to specific, time-limited, psychosocial programmes
that have been developed alongside the TPM.
Evidenced Based Psychosocial Intervention
164
Page No
Social behaviour and network therapy
97
Coping and social skills training
Behaviour self-control therapy
Relapse prevention therapy
89*
Motivational intervention
Motivational Enhancement Therapy
35*
Anxiety management therapy utilising a cognitive behavioural approach
93*
Sleep hygiene programmes for sleep disturbance
80*
12 step facilitation therapy
75
Community Reinforcement Approaches
69*
Anger management utilising a cognitive behavioural approach
94*