بسم الله الرحمن الرحیم

1. بسم الله الرحمن الرحیم مولود جعفری 881111408

2. Coping Skills Training For Addiction دكتر رضا باقريان گروه روانپزشكي دانشگاه علوم پزشكي اصفهان

3. Have you ever wondered why some people can drink alcohol or use a substance and walk away from it without developing an addiction? Have you ever

4. Addiction equation • Before I reveal the answer to that question let's review what I like to call the addiction equation. • Family dysfunctions causing emotional pain + low level of self-esteem + emotional coping skills + learned addictive behavior from surroundings, friends, and/ or family = ADDICTION!

5. Addiction equation • Emotional pain • Low level of self-esteem • Emotional coping skills • Learned addictive behavior

6. Coping strategies: • 1) Problem Oriented • 2) Emotional Oriented

7. A high level of self-esteem and coping skills. • Certainly, there are some people who experience physical, verbal, sexual abuse, and many other dysfunctional patterns that manage to lead perfectly, healthy, happy lives which are free of addiction. And, I would also venture to say that many of those same people have been subjected to examples of addictive behavior by their friends and/or family as well! So, why do these individuals opt "to just say no?" The answer is a high level of self-esteem and coping skills. • Low level of self-esteem • Coping skills deficits

8. Definition of the word cope • How you can increase your level of coping skills, so let's break it down. First, we need to define the word cope. • Cope; to deal successfully with a difficult problem or situation. Therefore, increasing your coping skills translates into improving your ability to deal with a difficult problem.

9. مفهوم مقابله • مفهوم مقابله به عنوان تلاشهاي شناختي و رفتاري به منظور تسلط يافتن بر موقعيتهاي تهديد آميز تعريف شده است. • بر اساس نظريه لازاروس و فولكمن رفتارهاي مقابله اي در رويارويي با استرس شامل دو فرايند مي شود: • فرايند مسئله-مدار كه طي آن فرد با مسئله اي كه علت واقعي آشفتگي در وي شده است مواجه مي شود • فرايند هيجان-مدار كه بر اساس آن فرد تلاش مي نمايد پاسخهاي هيجاني خود را تنظيم نمايد.

10. Intrapersonal Skills • Managing thoughts and cravings for use • Anger management • Negative thinking • Pleasant activities • Relaxation skills • Decision-making • Problem-solving • Planning for emergencies

11. Interpersonal Skills • These skills are taught for coping with situations in which other people are an important factor or are actually part of the problem. • Drink/drug refusal • Refusing requests • Handling criticism • Intimate relationships • Enhancing social support network • Assertiveness training • General social skills • Coping skills training with significant others

12. Uramanat - North-Western Iran

13. Etiology of addiction • Acquisition Phase • Maintenance Phase

14. Acquisition Phase: • Biological mechanisms (Brain Reward System) • Diffusion Superiority Feeling • Imitation • Hedonism Pleasure Seeking (Expertise) • Pain Relief • High Neuroticism • Socialization (Social Norms) • Impulsive Control Disorder • Personality Disorders (Anti social and Borderline) • Peer Influence • Availability • Low Self- Esteem • Mood Disturbances (Depression, Anxiety, Hostility) • Cultural Factors

15. Diffusion • Superiority Feeling • مصرف مواد مثلا ترياكبه فرد يك احساس superiority مي دهد حتي اگر معطوف به نتيجه مثبت نباشد و معمولاً از رده هاي بالا به پايين سرايت مي كند ( خواستم مثل آنها ( افراد بالاتر باشم). • خان معتاد به ترياك است بقيه براي اينكه خودشان را شبيه خان احساس كنند (احساس superiority ) ترياك مصرف مي كنند. يا در يك خانواده 5 الي 6 نفر معتاد هستند. مثل يك بيماري عفوني گسترش مييابد. در برخي شهرها يا محله ها بيشتر است.

16. Imitation • در imitation يادگيري رفتار با مزيت خالص فردي و معطوف به نتيجه مثبت است. مي تواند انگيزه و ادامه بر اساس لذت طلبي است.

17. Hedonism • Pleasure Seeking (Expertise) • افرادي كه pleasure seekingيا Hedonism هستند احتمال اعتياد بيشتري دارند. • انگيزه شروع مي تواند لذت طلبي باشد. • وقتي hedonism بالا باشد برنامه هاي درماني مبتني بر سخنراني، كلاس،..... نمي تواند مفيد باشد بلكه بايد در برنامه هاي درماني جنبه هاي pleasure و hedonic مورد توجه قرار گيرد.

18. مهارت در ايجاد لذت • منظور مهارت هايي است كه فرد ياد مي گيرد در ايجاد كسب لذت . وقتي كه فرد در طي رشد فرصت كسب مهارت هاي ايجاد لذت را پيدا نكند و در بزرگسالي در ايجاد لذت expert نمي شود لذا به سراغ لذت هاي خام كه مستقيماً مغز را فعال مي كند مي رود. بنابر اين به مواد به منظور كسب لذت هاي خام رو مي آورد . اگر مهارت هاي ايجاد لذت از طريق فعاليت هايي مانند هنر، بازي و نظاير آن در فرد رشد كند و فرد در آن مهارت پيدا كند، كمتر احتمال دارد كه به مصرف مواد گرايش پيدا كند. همچنين خود مصرف مواد باعث ميشود فرد در ايجاد ساير لذت ها مهارت نيابد. • براي لذت طلبي خط پايه اي وجود دارد . با مصرف مواد خط پايه لذت بالا مي رود و لذت ساير پاداش ها مانند سلامتي ، همسر، كار، فرزند، مسافرت نسبت به لذت مصرف مواد پايين تر قرار مي گيرد . بنابراين در درمان معتادها اين مسئله را بايد در نظر گرفت كه با ارائه اين پاداش ها نمي توان فرد معتاد را تشويق به ترك نمود چون پايين تر از خط لذت طلبي او قرار دارند. • ترغيب به فعاليتهاي پرهيجان نظير كوهنوردي، صخره نوردي، اسكي، مسافرت و ورزشهاي پرهيجان • در زندگي فرد برنامه هائي وجود داشته باشد تنوع و لذت باشد.

19. Pleasant activities • Clients may discover a void in their lives as free time becomes available once they are no longer so occupied with acquiring, using, and recovering from the effects of alcohol or drugs. • They may also find that they are leading an unbalanced lifestyle in which they fulfill numerous obligations, with little if any time devoted to recreation or self-fulfillment. • A session on developing a pleasant activities plan is intended to help clients prepare enjoyable, low-risk ways of filling the free time that will be opened up, and achieve a better balance between their obligations and more enjoyable or self-fulfilling activities. A number of strategies for selecting and engaging in these activities are identified.

20. Pain Relief • انگيزه كاهش دردهاي جسمي مي باشد. • اصلاح باورهاي غلط و آموزش مهارتهاي شناختي به منظور به چالش كشيدن اين باورهاي غير منطقي

21. High Neuroticism • افرادي كه high neuroticism هستند احتمال اعتياد بيشتري دارند.

22. Socialization • Social Norms • Non-Assertiveness

23. Peer Influence • گروه همقطاران و دوستان باعث فشار جمعي شده و به خصوص در افرادي كه رشد اجتماعي مناسبي نداشتند و توان ”نه“ گفتن ندارند مي تواند باعث روآوري به مواد شود.

24. Assertiveness training • May be offered to enable clients to express their emotions and opinions clearly and directly, in a manner that leaves them satisfied that their views were heard, but without doing so in a way that alienates or antagonizes others.

25. Drink/drug refusal • Knowing how to cope with offers to use alcohol or drugs is an important skill for the majority of chemically dependent clients because such offers are fairly common. • Clients are taught to say ‘no’ convincingly without giving a double message, to suggest an alternative activity that does not involve substance use, to change the subject to a different topic of conversation, and if the other person persists, to ask him/her not to offer alcohol or drugs any more. • With considerable practice of this skill, clients should be able to respond quickly and convincingly when these situations arise. • Role-playing of refusal scenes progress from ones that are easy to handle, building to more persistent offers that are difficult to refuse. • The homework exercise involves planning how to respond in a variety of different situations in hich alcohol or drugs may be offered.

26. Refusing requests • People often feel discomfort when refusing other peoples’ requests for favors, and therefore may tend not to do so. However, failure to refuse to do something they really don’t want to do can leave them feeling imposed upon, self-critical, resentful, or angry, any of which may serve as triggers for cravings or use of alcohol/drugs. • Clients are taught to refuse unwanted requests by first acknowledging the requesting person’s position and feelings, and to then make a firm, clear statement of refusal. • They are also taught to consider whether or not a compromise might be appropriate under the circumstances. Opportunities to role-play request-refusal are provided in the session, and for homework clients are asked to formulate responses they might use in situations of this type that they are likely to encounter.

27. Impulsive Control Disorder

28. Personality Disorders • Antisocial Personality Disorder • Borderline Personality Disorder

29. Availability

30. Low Self Esteem • در هنگام فشار جمعي يا craving افراد با اعتماد به نفس بالا داراي توان امتناع كردن خواهند بود • ودر مقابل افراد با اعتماد به نفس پائين داراي توان امتناع كردن و ”نه“ گفتن ندارند. • برخي از افراد با اعتماد به نفس پائين افرادي هستند كه تحمل ناكامي را ياد نگرفته اند.

31. Assertive training • May be offered to enable clients to express their emotions and opinions clearly and directly, in a manner that leaves them satisfied that their views were heard, but without doing so in a way that alienates or antagonizes others. • Training for increasing Self Esteem

32. Mood Disturbances • Depression • Anxiety • Hostility

33. Relaxation skills (Anxiety) • Relaxation may be a useful way of coping with various circumstances that either precede or are exacerbated by alcohol/drug use, such as stress, tension, anxiety, anger, sleeplessness, and cravings to use. • Skills training involves alternate tensing and relaxing of various muscle groups, to enable clients to identify tension states and their alternative, relaxation. In addition to relaxation of muscle groups, clients are taught slow breathing and the use of calming imagery. As these skills are practiced and acquired, clients can be taught to apply them in various situations, stressful ones in particular.

34. Negative thinking (Depression) • This is another common high-risk situation. Separate skills training sessions are available for increasing one’s awareness of negative thinking and for managing it when it occurs. Clients are taught to recognize various types of negative thinking habits that may occur automatically.Skills for managing negative thoughts include substituting positive thoughts or feelings, thought stopping, and positive self-talk. • Exercises give clients practice in identifying their negative thinking and negative self-talk, and provide an opportunity for them to prepare alternative, substitute responses. A related common problem is negative moods and/or depression.

35. Anger management (Hostility) • Anger is a very common antecedent to alcohol/drug use. • Clients are taught about the warning signs of anger, both external and internal signs, so they can identify them early and begin to manage them before anger grows strong and becomes harder to control. • Skills for managing anger include the use of calm-down phrases, identifying aspects of a situation that are provoking anger, and considering options that might help to resolve the situation. These skills can be modeled by the therapist and then role-played by the client. • For homework, clients are asked to record their handling of the next anger situation they encounter.

36. Cultural Factors

38. Maintenance Phase • Relapse equation: Cues + Negative mood and Positive mood+Urge +Expectations + Activation of Brain Reward System * Low Self Efficacy = Relapse or No Relapse Cues Negative mood and Positive mood Urge Expectations Physiological Factors Low Self Efficacy

39. Maintenance Phase • Classical Conditioning • Hedonism • Expectancy (Cognitions) • Stigma • Low Self Efficacy • Stereotypes: Irrational Beliefs • Low Abuse + Stress = Heavy AbuseComplication

40. Hedonism • Incearsed Hedonic Hemostasis (Expertise)

41. Pleasant activities • Clients may discover a void in their lives as free time becomes available once they are no longer so occupied with acquiring, using, and recovering from the effects of alcohol or drugs. • They may also find that they are leading an unbalanced lifestyle in which they fulfill numerous obligations, with little if any time devoted to recreation or self-fulfillment. • A session on developing a pleasant activities plan is intended to help clients prepare enjoyable, low-risk ways of filling the free time that will be opened up, and achieve a better balance between their obligations and more enjoyable or self-fulfilling activities. A number of strategies for selecting and engaging in these activities are identified.

42. Classical Conditioning • وقتي كه cue ها ظاهر مي شود نظير (منقل، اتاق مصرف، علائم جسمي يا افراد) فرد دچار خلق منفي، بيقراري و نا آرامي ( علائم محروميت) مي گردد. سپس دچار وسوسه شده و منجر به مصرف مواد مي شود. • CueActivation of Brain Reward System Withdrawal Symptoms Craving Relapse

43. Craving • چهار نوع وسوسه مي توان از يكديگر متمايز ساخت: • وسوسه ناشي از محروميت • وسوسه ناشي از خلق منفي • وسوسه ناشي از خلق مثبت ( مثل هوس كردن) • وسوسه ناشي از cue ها • Cue Desensitization

44. Managing thoughts and cravings for use • Thoughts about drinking or drug use, and their more intense version, cravings, are common among people recovering from substance use disorders, and therefore this training module is generally used with all clients. They are taught a number of skills for managing thoughts and cravings, including challenging them, recalling unpleasant experiences that resulted from using, anticipating the benefits of not using, distracting oneself, delaying the decision whether or not to use, leaving the situation, and seeking support. • Clients are given a 3x5 card on which to record the unpleasant effects of past use and the anticipated benefits of not using, and are instructed to carry it with them and refer to it whenever they think of using. • They are also asked to imagine various high-risk situations, and practice coping with the thoughts and cravings that might accompany them.

45. Expectancy Positive Expectancy Negative Expectancy اگر مواد مصرف كنم مي دانم كه دردها و علائم جسمي رفع مي شود اگر مواد مصرف كنم مي دانم كه حالم بدتر مي شود.

46. Stigma • Stigma (منظور كليشه هاي رايج درباره فرد معتاد است )نظير بي عرضه، به درد نخور، بي اراده ) اين كليشه ها Self Esteem را به شدت خراب مي كند. • Stigma Low Self EsteemGrandiosity • گاهي اين كليشه ها با خدشه دار كردن Self-steem معتاد را در موضع دفاعي قرار مي دهند. و باعث تلاش وي براي حفظ Self Esteem مي شوند. اين تلاش ها در اكثر موارد به صورت بزرگ منشي تظاهر مي كند كه اصطلاحاً حرف هاي پا منقلي مي گويند.

47. Low Self Efficacy

48. Stereotypes: • Irrational Beliefs • Schema • مصرف مواد در ابتدا باعث تخفيف خلق منفي و تقويت خلق مثبت مي شود. در نتيجه تكرار اين تاثير طرحواره هاي شناختي مربوط به آن شكل مي گيرد. نظير آن كه مواد مخدر من را آرام مي كند ، يا حالم را بهتر ميكند. وقتي اين طرحواره ها شكل گرفت در آينده در اثر فعال شدن آنها در نتيجه استرس فرد مجدداً به مصرف مواد رو مي آورد. يعني به طور اتوماتيك اين طرحواره ها درذهن فرد فعال مي شود و براساس آن فرد نياز به مصرف مواد پيدا مي كند. • آموزش مهارتهاي شناختي به منظور شناسائي، به چالش كشيدن افكار كليشه اي، جايگزيني و ارزيابي

49. Chehel Sotoun Palace Pavilion - Isfahan

50. Intimate relationships • Some clients may experience difficulty expressing their feelings, or communicating effectively and sensitively in intimate relationships, especially where there is considerable conflict and tension as a result of substance use. This can be a bar to intimacy, both emotional and sexual. • Clients are taught about self disclosing their emotions, sharing their positive feelings, and the importance of expressing negative feelings (in an appropriate way) to prevent things from building up. • They may also be taught listening skills, which are an essential component of an intimate relationship. • Clients practice these skills in simulated situations drawn from their recent past in which they felt angry, anxious, or sad with loved ones. • Homework involves planning how to handle one such situation, and then actually trying out the skills in it.