Welcome to the South Hills Recovery Project Core Addiction Skills For Recovery Workbook. This workbook leads you through the steps necessary to recover the life you deserve. The exercises in this workbook are designed to assist in the “rewiring” of your brain. During the time you were addicted, the drug gradually changed how you thought, felt, and acted. This abnormal “rewiring” caused catastrophic results. Your thoughts, feelings, and behavior changed in a manner which made it impossible to stop drug use on your own. It altered your ability to make decisions consistently that aligned with your desired goals. When you put down all addictive drugs, your brain began the process of rewiring back to a healthy state. As your brain wiring returns to normal, you feel better, think better, and act better. It is this change that gives you the results you seek. To get the best results, the following exercises focus on those brain functions that suffered the most from the disease of addiction. These exercises also assist in correcting brain circuits that may have been functioning improperly before you started using the drug. Trouble coping with life’s problems contributed to your drug addiction. When you recover, through a process called neuroplasticity, your brain will correct itself if you follow several basic recommendations. It is one of the miracles of the human body that you heal naturally. However, just like if you had a car accident, and needed physical therapy, these exercises help you direct the healing process of your brain to get the most out of treatment.
Take a few minutes now to imagine where you want to be one year from now. Five years from now? See it in your mind’s eye: the more detail, the better. You are developing a “blueprint” for the reconstruction of your brain. As the old saying goes, “What we can conceive, we can achieve.” What you hope to achieve in recovery is based on the images in your head, what we imagine. Those ideas and images most vital to you consistently stay in your consciousness. It is the reward you chase now. It is what you want to happen in your life. You will get the poor results if you imagine your future incorrectly. For example, if in your future, you imagine continued use of a drug, but in a controlled manner, you will build your life with drug use included. As you may know, that will cause your hard work, pain, and sacrifice to be wasted. As you will read in the first section of this workbook, your brain responds to the drug much differently than people without addiction. If you use again, you will find out, again, that you eventually lose control. You get the same result as before. You will circle back to the place you find yourself now. If you are lucky, you learn from this error in thinking and have the chance to recover fully finally.
Whether it is your first time beginning the recovery process, the second or third, you may be discouraged. Your life had not gone the way you expected. At first, you blamed the world and those that live in it. Later, you blamed yourselves. Like we say in recovery, it is easy to fix the blame on someone or something, but we get much better results fixing the problem. Take a break from blaming yourself or others, relax and forgive. How things turned out in our lives is not our fault. Our genetics, family of origin, our early experiences are far more responsible for our current condition than we are.
Be kind to yourself. A person’s character is defined not by what has happened to him/her, but how they chose to deal with those events. History is full of men and women who achieved miraculous things in life because they were handled with overwhelming challenges early on. A philosopher, G. Michael Hopf said, “Hard times create strong men. Strong men create good times. Good times create weak men. And, weak men create hard times.” Substitute the word women, because it is true for women as well.
The good news is you are alive and can get it right this time. All you need to begin is honesty, willingness, and openness to a new way to look at old problems. Refuse to hide your drug use. Abandon old notions of what you think it will take to heal. We will provide you with expert advice. Some of us have the same disease and learned to rise above it. We will guide you as you build back the life you deserve. The process of letting go of your firmly held belief about what will make you better is called “surrender.” We will suggest actions that will help you. Even if you don’t think it will help, or is not worth the effort, do it anyway. Surrender control. This is how the brain “rewiring” works — doing something different. Overcoming reluctance. You can do the work. Don’t allow yourself to think, “It’s too much, I can’t do it.” We all thought this in the beginning but were encouraged by others further along in the rebuilding process. They had a life you wanted. All you have to do is show up for duty, and take it “one day at a time.” If you feel “I can’t” tell us. We will encourage you. However, beware keeping this a secret. Pretending to honest, willing, and open-minded will get you nowhere. You will be the last to know that we already saw this. And after many attempts to motivate you, we will say we both will discover can’t help you. We won’t waste your time and ours pretending you are getting treatment. We will refer you to treatment better suited for you, or allow you to find your own way.
This manual is a guide for the awesome project of “rewiring” your brain. The best life you can imagine for yourself is your ‘blueprint’ for this rebuilding. The Core Skills Workbook will provide you with the tools required for the reconstruction. Better tools, easier work, better results. It takes some effort upfront to learn the necessary tools for the project, but you will be very glad you have these tools. Having developed good tools and learning to use them while in your treatment here will benefit you now and after treatment is completed.
Remember we gave you this carefully crafted workbook because we saw you had great potential. Potential to achieve what you think is impossible. Tell yourself now that the word impossible includes, I’m possible” If you can’t believe in yourself now, let us believe in you. If you are willing to give your best effort, keep an open mind, and are honest about your struggles, you will begin to believe in yourself soon. The results will prove it. If you are not willing to do the work and want to stick with your own idea of how to get better, don’t make the mistake of hiding it. Be honest. Tell us how you really feel. We will understand. Not all of you are ready to change right away. Pretending to be willing, open, and honest will not help you. Realize life provides few opportunities for meaningful and satisfying growth, usually right after we undergo a life crisis. The next opportunity to change and grow may require yet another crisis.
The Core Skills Workbook begins with the basics. How did we get addicted? What is addiction? What is the best way to deal with addiction? How do we start our process of recovery? Use the workbook like a roadmap for the recovery process. It will help you plan recovery from one day to the next.
Later in the workbook, you will learn the skills required to reduce and eliminate anxiety, depression, and stress, and unhealthy anger. Next, you will learn how to deal with shame, guilt, and improve self-esteem. We will address common work-related problems like job burnout and handling “toxic: people. Next, you will work on improving your health, relationships, and finances. In the end, you will learn how to keep the recovery process going throughout your life. By working the exercises at the end of each section, you will begin the “rewiring” process. Applying the exercises in your life will complete the “rewiring” through repeated use, and practical application. This is the most important part. Use the skills chosen in your real life. If you don’t, chances are you will not “rewire” permanently and eventually slip back into the old, unproductive patterns already wired in.
We will review your work in this workbook at your therapy sessions. It is a very important part of the rewiring process. We will encourage your success and ease your struggles. Our help will be more exact, useful, and rewarding when we work on your goals together. Alternatively, you can bring in a journal, notebook, or mobile phone that you use to remind yourself to practice the exercises. You are three times more likely to complete an action if you write it down. Remember, you don’t need to start with dramatic changes that seem impossible. Just take the next few steps towards your goals. As a great Chinese philosopher, Confucious, said, “ A journey of a thousand miles begins with a single step.” Learn to take action one day at a time. This journey one day at a time. If you do what right today is, tomorrow will take care of itself.
Your first step towards the life you desire must be to understand what derailed you. When you walked into our clinic, you came because you realized that you had a drug addiction and that addiction to drug was the root of most troubles. This realization was born from the increasing number of unmanageable problems that piled up in your life. You came to realize if you did not get help, your life was sure was going to get worse.
You were ashamed of yourself. You feared terrible judgment. You were ashamed to show up at the treatment clinic. You were angry that you could not fix the drug problem yourself. Some of your anger came from the failed experiments at controlling drug use. You hoped you could take a break, and go back to controlled use a drug or drugs. Or, you were sure that, with Suboxone, you could use when you wanted, take suboxone when you couldn’t get your drug of choice or wanted to take a break. Those who believe that they still have control ended up taking the elevator of life down a few more floors. Some got off on the bottom floor in jail or a hospital. Others took the elevator to their death. The truth has always been that addiction means you gradually take more drug than you expect, more often than you wanted, despite mounting consequences of your drug use. With the increase in use, the drug changes areas in your brain that control that use. Before you were aware of it, you lost the ability to stop on your own. Instead of making a well-reasoned decision about drug use, you begin to rationalize drug use as something “I need.” You minimized the problems and risks caused by the use of the drug. You refused to see it. You became angry and defensive with people who care about you when they voice their concerns.
Let’s start with the origin of our problem. What is addiction exactly?
People feel pleasure when basic needs, such as hunger, thirst, and sex are satisfied. In most cases, these feelings of pleasure are caused by the release of dopamine in the brain. Most addictive substances cause the brain to release high levels of dopamine that is associated with pleasure or reward. Addictive drugs can release 2 to 10 times the amount of dopamine that natural rewards do, and they do it more quickly and reliably.
Over time, continued release of dopamine causes changes in the brain systems involved in reward, motivation, and memory. When these changes occur, a person may need the substance to feel normal. The individual experiences intense desires or cravings for the addictive substance and will continue to use it despite the harmful or dangerous consequences. The person will also prefer the drug to other healthy pleasures and may lose interest in normal life activities. In the most chronic form of the disease, addiction can cause a person to stop caring about their own or other’s well-being or survival.
Short Definition of Addiction:
Addiction is a primary, chronic disease affecting brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use.
Addiction is characterized by the inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
Long Definition of Addiction:
Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational ranking are altered and addictive behaviors supplant healthy, self-care related behaviors. In other words, the drug becomes more important than family, job, and freedom. Addiction affects neurotransmission and interactions between cortical (reasoning) and hippocampal (memory) circuits and brain reward structures, such that the memory of previous exposures to drugs leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.
The neurobiology of addiction encompasses more than the neurochemistry of reward. The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation, and memory are altered with continuous drug use. Decreased impulse control, altered judgment, and dysfunctional pursuit of the drug (which is often experienced by the affected person as a desire to “be normal”) are the result with cumulative adverse consequences to the individual sufferer. The frontal lobes are important in inhibiting impulsivity and in assisting individuals to delay gratification appropriately. When persons with addiction have problems in delaying gratification, there is a neurological cause of these problems in the frontal cortex. Frontal lobe structure, connectivity, and functioning are still in the process of maturation during adolescence and young adulthood. Early exposure to substance use makes a person 40% more likely to develop an addiction.
Genetic factors account for about half of the likelihood that an individual will develop an addiction. Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. Healthy early life experiences the individual acquires (through parenting or later life experiences) can limit the extent to which genetic predispositions lead to addiction in that individual. Culture plays a role in how addiction develops in persons with the genetic differences that predispose toward the development of addiction. Drug addiction is characterized by the following:
The presence of an underlying biological deficit in the function of reward circuits, such that drugs which enhance reward function are craved and chased as extremely pleasurable and/or necessary.
The repeated engagement in drug use is causing changes in motivational circuitry in the brain leading to impaired control over further drug use.
Changes in emotional response and thinking, resulting in significant self-deception (i.e., drug use helps us function better).
Disruption of healthy social supports and problems in interpersonal relationships which affect the ability to get support from family and friends (we hide form people).
Exposure to trauma or stressors that overwhelm an individual’s coping abilities; ( jails, loss of a job, divorce)
Changes in meaning, purpose, and values in the drug user’s life that affect attitudes, thinking and behavior; (feeling no use)
Changes in a person’s view of self, others, and with their spiritual beliefs. (we become self-centered)
The presence of co-occurring psychiatric disorders in persons who engage in substance use.
In summary, addiction is characterized by:
Inability to consistently abstain;
Impairment in behavioral control of drug use;
Craving; or increased “hunger” for drugs or rewarding experiences;
Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
A dysfunctional emotional response.
Persistent risk and/or recurrence of relapse, after periods of abstinence, is another fundamental feature of addiction. This can be triggered by exposure to the drug, exposure to environmental cues to use, and exposure to emotional stressors that trigger heightened activity in brain stress circuits.
People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives and display an apparent lack of appreciation of the magnitude of cumulative problems and complications.
Behavioral problems seen in addiction can include:
Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control;
Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g., the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);
Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors;
A narrowing of the person’s interests and habits focusing on rewards that are part of addiction; and
An apparent lack of ability and/or readiness to take consistent action to get help for the drug addiction despite recognition of problems.
Changes in thought processes in addiction can include:
Preoccupation with substance use;
Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and
The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.
Emotional changes in addiction can include:
Increased anxiety, dysphoria, and emotional pain;
Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and
Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).
The emotional aspects of addiction are quite complex. Some persons use drugs because they are seeking “positive reinforcement” or the creation of a positive emotional state (“euphoria”). Others pursue substance use because they have experienced relief from negative emotional states (“dysphoria”), which constitutes “negative reinforcement.“ Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviors. The state of addiction is not the same as the state of intoxication. When anyone experiences mild intoxication through the use of drugs, or when one engages non-pathologically in potentially addictive behaviors such as gambling or eating, one may experience a “high,” felt as a “positive” emotional state associated with increased dopamine and opioid peptide activity in reward circuits. After such an experience, there is a neurochemical rebound, in which the reward function does not simply revert to baseline, but often drops below the original levels. This is usually not consciously perceptible by the individual and is not necessarily associated with functional impairments.
Over time, repeated experiences with substance use or addictive behaviors are not associated with ever-increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use, there is an anxious, agitated, dysphoric and labile emotional experience, related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs. While tolerance develops to the “high,” tolerance does not develop to the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in addition, persons repeatedly attempt to create a “high”–but what they mostly experience is a deeper and deeper “low.” While anyone may “want” to get “high,” those with addiction feel a “need” to use the addictive substance or engage in the addictive behavior to try to resolve their dysphoric emotional state or their physiological symptoms of withdrawal. Persons with addiction compulsively use even though it may not make them feel good, in some cases long after the pursuit of “rewards” is not pleasurable. Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice.
These changes in the brain can remain for a long time, even after the person stops using substances. It is believed that these changes may leave those with addiction vulnerable to physical and environmental cues that they associate with substance use, also known as triggers, which can increase their risk of relapse.
Simply put, addiction is not a desired condition.
Clinical interventions can be quite effective in altering the course of addiction. Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in health promotion activities which promote personal responsibility and accountability, connection with others, and personal growth also contribute to the recovery. It is important to recognize that addiction can cause disability or premature death, especially when left untreated or treated inadequately.
As is the case with other chronic diseases, the condition must be monitored and managed over time to:
a. Decrease the frequency and intensity of relapses;
b. Sustain periods of remission; and
c. Optimize the person’s level of functioning during periods of remission.
In many cases of addiction, medication management can improve treatment outcomes. In most cases of addiction, the integration of psychosocial rehabilitation ( correcting problems which trigger drug use) and ongoing care provides the best results. Chronic disease management, doctor’s visits over a long period of time, is important for minimization of episodes of relapse and their impact. Treatment of addiction saves lives
Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery.
Recovery from addiction is best achieved through a combination of self- management, mutual support, and professional care provided by trained and certified professionals.
Chronic disease is a long-lasting condition that can be controlled but not cured. About 25-50% of people with a substance use problem appear to have a severe, chronic disorder. For them, addiction is a progressive, relapsing disease that requires intensive treatments and continuing aftercare, monitoring, and family or peer support to manage their recovery.
The good news is that even the most severe, chronic form of the disorder can be manageable and reversible, usually with long term treatment and continued monitoring and support for recovery.
The initial and early decisions to use substances reflect a person’s free or conscious choice. A drug may be started by a doctor. However, once the brain has been changed by addiction, that choice or willpower becomes impaired. Perhaps the most defining symptom of addiction is a loss of control over substance use.
People with addiction should not be blamed for suffering from the disease. All people make choices about whether to use substances. However, people do not choose how their brain and body respond to drugs and alcohol, which is why people with addiction cannot control their use while others can. People with addiction can still stop using – it’s just much harder than it is for someone who has not become addicted.
People with addiction are responsible for seeking treatment and maintaining recovery. Often they need the help and support of family, friends, and peers to stay in treatment and increase their chances of survival and recovery.
Some people think addiction cannot be a disease because it is caused by the individual’s choice to use drugs or alcohol. While the first use (or early-stage use) maybe by choice, or doctor’s prescription, once the brain has been changed by addiction, most experts believe that the person loses control of their behavior.
The choice does not determine whether something is a disease. Heart disease, diabetes, and some forms of cancer involve personal choices like diet, exercise, sun exposure, etc. A disease is what happens in the body as a result of those choices.
Others argue that addiction is not a disease because some people with addiction get better without treatment. People with a mild substance use disorder may recover with little or no treatment. People with the most serious form of addiction usually need intensive treatment, followed by lifelong management of the disease. However, some people with severe addiction stop drinking or using drugs without treatment, usually after experiencing a serious family, social, occupational, physical, or spiritual crisis. Others achieve sobriety by attending self-help (12-step or AA) meetings without receiving much, if any, professional treatment. Because we do not understand why some people are able to stop on their own or through self-help meetings at certain points in their life, people with addiction should always seek treatment.
The images below show how scientists can use imaging technology to measure the functioning of the brain. Greater activity is shown in reds and yellows, and reduced activity is shown in blues and purples. The healthy brain shows greater activity than the diseased brain because addiction cause changes in function. In drug addiction, the frontal cortex, in particular, shows less activity. This is the part of the brain associated with judgment and decision-making
The brain can recover – but it takes time!
How the brain recovers from addiction is an exciting and emerging area of research. There is evidence that the brain does recover; the image below shows the healthy brain on the left, and the brain of a patient who misused methamphetamine in the center and the right.
In the center, after one month of abstinence, the brain looks quite different than the healthy brain; however, after 14 months of abstinence, the dopamine transporter levels (DAT) in the reward region of the brain (an indicator of dopamine system function) return to nearly normal function (Volkow et al., 2001).