Recovery Training Program for Compulsory DRCs in China

1. Recovery Training Program for Compulsory DRCs in China Dr. Mark E. Barrett, Consultant UNODC Ms. Karen Mah Yien Ling, Trainer UNODC July 2004

2. Part two: Recovery Training Program • Today we will present a basic 10-mod recovery training program that can be used within the DRCs to provide addicts with knowledge and skills to aid in their recovery from drug addiction. • This recovery program is just a beginning and if interest develops it could be expanded. • The sessions will be self-explanatory and easy to use by DRC staff, requiring a minimum of preparation.

3. Sources for this Information • This simplified “Recovery Training Program” is based on principles derived from the 12-step program of Alcoholics Anonymous/ Narcotics Anonymous, Relapse Prevention Training and other recovery training materials. • The idea is to try to pinpoint the most important principles and practices for rehabilitating heroin users in China.

4. Modules of Recovery Program • The 10 modules can be organized into 5 general areas, as follows: • 1. About Addiction (1) • 2. Stages of Change (1) • 3. Lifestyle Change/ Return to Society(4) • 4. Relapse Prevention (3) • 5.Aftercare(1)

5. Guidelines for Conducting Recovery Training Sessions • The ten modules can best be covered over a 10-week period. • It would be best to be flexible and devote as many sessions as needed for each module. • Addicts will need some time for processing the information and to do homework. • The sessions are meant to be interactive; although there is some teaching, much of the time will involve discussion and skill building activities.

6. Guidelines for conduction sessions • For each module there will be a statement of the objectives and then step-by-step instructions. Blue Font passages can be read out loud. • The instructor/trainer may wish to add their own materials and generate examples that will be relevant to the addicts’ lives. • A time period of 60 -90 minutes will be ideal. • Working with smaller groups of around 8-10 persons will be best.

7. Addict Involvement in Program • The addicts will be expected to participate actively in the sessions. • It is suggested that each of them keep a notebook for making notes and doing some of the activities. (This should be kept somewhere private as it may contain very personal information).

8. Method of Training • The trainer should try and adopt the approach known as Motivational Interviewing. This approach assumes that the responsibility and capability for change lies within the addict. • Motivation is something that can be influenced by others and is not a personality characteristic or trait. • Participants should also be taught to use the motivational approach in their interactions.

9. Principles of MI • Express empathy: listen without judgment, criticism or blame and try to gain a better understanding of the addict from his/her viewpoint. • Develop discrepancy: help the addict to see the discrepancy between the past and present behavior, and future goals. This is done by examination of the consequences of continued drug use; look at the pros and cons of changing or continuing to use. Hopefully the addict will see the need for change.

10. Avoid argumentation: when encountering resistance it is time to change strategies. Most addicts will not become willing to change if they do not feel supported and are forced to become defensive. MI is a non-confrontational approach. • Support Self-efficacy: try to help the addict to build confidence in his/her ability to change.

11. Motivational Strategies • Ask open-ended questions: avoid simple yes/no questions. • Listen reflectively: make statements that reflect back what you think the client is telling you. • Example: • “I hear you saying that you are afraid of what might happen when you leave the center…”

12. Affirm: show positive regard and support the addict’s efforts to change with complements and statements of appreciation and understanding. • Summarize: Periodic summaries will help link together what has been discussed, show the addict that you have been listening and help to point out ambivalent issues. A summary at the end of the session will help to pull together clearly and succinctly what has transpired during the session.

13. Leading the groups • It is strongly recommended that the trainer review the module several times before conducting a session. • Trainers should establish the norms/rules for how members behave in the group. • These norms/rules should be discussed at the very beginning and reviewed periodically.

14. Helpful Norms for Group Behavior • Non-judgmental acceptance of others • Willingness to self disclose • Participation by all group members • Respecting confidentiality • Valuing the importance of the group • Recognizing the available support in the group • Respecting others ( constructive criticism, no name calling) • Willingness to accept feedback

15. Leading the groups • Maintain a safe environment: emphasize confidentiality, discourage inappropriate remarks and interactions. • Help the addicts to stay in the “here and now.” Addicts sometimes like to dwell on the past rather than looking at the present and future. • LETS BEGIN!

16. Module One: About Addiction • Introduction: This will be an awareness raising module and for some it may be their first step towards understanding what has happened to them as a result of using heroin for months or years. • Objective: participants will learn about addiction and its effects on brain and behavior, and what this means for recovery.

17. Introduction • Given that this is the first session it would be a good time to explain about the ground rules of behavior in the group. (Some suggestions for rules were given earlier.) • Also, it would be good to have all the members introduce themselves by telling their names, where they are from, how long they have been at the center and so on. • Explain also about keeping a personal notebook and how this is to be used.

18. Begin Session One • Introduce topic for today and begin by asking participants What is addiction? How is addiction different than drug misuse? • Write down the various answers on the chalk board. (After explaining about addiction you can later come back and compare definitions and identify misunderstandings).

19. Drug Misuse versus Addiction • Drug misuse is the inappropriate, unsafe or illegal use of drugs by choice, versus drug addiction, in which the addict has lost most power of choice. • Drug misuse is a behavioral problem that responds to coercion, education, and decreased availability, whereas drug addiction usually require intensive multi-dimensional therapy.

20. Information on Addiction • Explain the following points to the group: • People start taking drugs for many reasons. Perhaps members of this group can recall how they first started? (Encourage discussion; ask a few to try and recall their first use of heroin--who, what, where, when, why?) • Some possible reasons to look for are: curiosity, boredom, peer pressure, taking drugs to feel better, and so on.

21. APA Definition of Addiction The American Psychiatric Association's diagnostic manual defines addiction as follows: "The symptoms include tolerance (a need to increase the dose to achieve the desired effect), using the drug to relieve withdrawal symptoms, unsuccessful efforts or a persistent unfulfilled desire to cut down on the drug or stop using it, and continued use of the drug despite knowing of its harm to yourself or others."

22. Information on Addiction • Tolerance: needing more and more of the drug to feel the effects, and • Physical Dependence: experiencing craving for the drug and having withdrawal symptoms (sickness) such as sweating, shaking, diarrhea, cramps, insomnia, and feeling anxious when unable to take the drug. • Tendency to relapse: for many addicts it may take years to recover and there may be many episodes of relapse.

23. Addictive Drugs • There are many addictive drugs: heroin, amphetamine, tranquilizers and alcohol, nicotine are the most common ones. • Scientists have discovered that all of these drugs act on the brain at a place called the “Brain Reward Center.” Addictive drugs make you feel good, and they also cause long lasting alterations to the nerve cells in the brain. This is why it is so difficult to stop! • (Explain this to participants and probe to be sure they understand what this means)

24. Addiction • We say that addictive drugs are “habit forming” because we have learned to keep taking them and become dependent on them just to feel normal. • It becomes very difficult to stop using drugs, not because you are weak willed, but because the brain keeps telling the addict to take drugs. • Becoming dependent on drugs involves changes in every area of one’s life, • Therefore: Recovery requires undoing years of faulty learning and physical changes to one’s brain. You didn’t get this way overnight, and it will take many months to recover fully.

25. Information on Addiction • How many of you have experienced craving for heroin? Craving is an uncontrollable hunger or desire for the drug, during which the addict cannot stop thinking about and wanting to use heroin. It can result in relapse for addicts who are not prepared to cope with it. • Discuss all of the above and make sure that addicts understand what addiction is. Compare to their definitions given earlier.

26. Harm to Self and Others • Physical health becomes worse (danger of disease such as HIV, hepatitis, overdose etc.) • Become less stable emotionally; more prone to anxiety, depression, low self esteem. • Personality changes (irritable, moody) • Relationships with family and friends become stressed or damaged. • Financial and legal problems (e.g., stealing, selling drugs to get a “fix”) • Interest in normal activities declines; drugs become center of one’s life.

27. Drug Screening Inventory • Here are some questions that might help you to decide, if you haven’t already, whether you feel you have become dependent or addicted to heroin. Answer these concerning the 12 months before you came into the DRC. Ask the participants to write down a “yes” or “no” for each question. Try to explain each question by giving examples and so on. • 1. Have you had to use larger amounts of the drug to get the same effects as before? • 2. Have you experienced withdrawal symptoms (such as shaking, sleeping problems, diarrhea) or used drugs to make withdrawal symptoms go away?

28. 3. Have you wanted to cut down on your drug use, or tried to cut down and couldn’t? • 4. Have you spent a great deal of time getting, using, or getting over the effects of drugs? • 5. Have you given up important activities because of drug use. • 6. Have you kept using drugs even though you knew it could make you more physically sick or emotionally upset than usual? • 7. Have you used larger amounts than you intended to, or for longer periods of time than you intended to?

29. Ok, if you answered yes to two or more of these questions you have been dependent and are probably addicted to heroin. If you answered less than two you may be at an earlier stage of dependence, or possibly engaging in drug misuse. Note: sometimes addicts may be unwilling to admit to the symptoms in the checklist and will make rationalizations and excuses for their behavior. This may take time for some, and perhaps it would be good to allow them several days to think about this.

30. Compulsory Treatment • Most of the participants were placed in the DRCs by police, and some may not have used heroin for a long period. • It will be important to explore their feelings about being in the DRC and try to help them find the motivation to change their drug use even for those who have not yet become dependent. • This can be done by having them do a “cost/benefit” analysis, weighing the pros and cons of continuing drug use after the DRC.

31. Addiction and Recovery • Many addicts would like to believe that they can stop using drugs by just making a simple decision to quit. After all the trouble that heroin has caused in their lives, they feel determined to never use again. • While this is important to make a firm decision in the beginning , it is not enough. Usually, within 90 days after finishing treatment two-thirds will relapse to addicting drugs • Once a person is addicted they usually need help in stopping drug use.

32. Addiction • How many of you feel you can leave the DRC and stay abstinent on your own? • “How many feel that you can stay abstinent if you can get supportand help? • Discussion about what it means to “need help”. Compare with other illnesses, like diabetes and need for treatment. • Recovery Training is learning how to help your self and to get help to stay abstinent.

33. Summary and Review • We have learned about addiction and how it affects our brain and behavior. • The important point that you should take away from this is that addiction has caused profound changes in your lives, affecting your brain and physical health, your emotional and mental health and your relationships with others and society. In order to recover from this you will have to take action to learn how to live a happy and successful life without drugs.

34. HOMEWORK • 1. Draw a line down the middle of a page in your notebook. • On one side list all of the good things you can think of about using heroin. • On the other side list all of the bad things about how heroin use has affected you and others around you. • 2. Why is it so difficult for addicts to stop using heroin? • 3. What will you have to do to recover from heroin addiction and stay abstinent?

35. Module Two: Stages of Change • Introduction: This module will present the Stages of Change model. After reviewing the model the trainer will question what it means to be at different stages. The participants have been asked to write down the “Pros” and Cons” of using heroin. This will be good preparation for examining what stage they are at. • Objective: Learn about the Stages of Change model, and to make a personal evaluation of the stage that each participant is at with respect to changing heroin use.

36. Begin Session Two • The next step will be to look at the Stages of ChangeModel and to explore the meaning of recovery from addiction. • Having learned something about the nature of addiction in Module 1, you can next ask yourselves the very important question about whether you are ready to change your drug use.

37. Stages of Change • People who change a self-defeating behavior, like addictive drug use, typically go through the following change sequence: Pre-contemplation  Contemplation  Preparation Action Maintenance • Addicts can cycle through this many times in their lives. For example after staying abstinent and then relapsing, the addict might be back to pre-contemplation again.

38. Stages of Change

39. Where am I? • Pre-contemplation: not aware of a problem with heroin; perhaps feel coerced into going into the DRC but feel there is no real problem other than conflict with the law. • Contemplation: have been thinking about quitting; wondering how my drug use is affecting others; maybe trying some small changes, like cutting down the amount.

40. Preparation: Have made plans to quit; maybe have already “cut down” the amount used; can definitely see that the costs of using are greater than the benefits. • Action: Have quit using already; am avoiding situations that might cause me to use; asking for support and help from others to quit stay abstinent; “changed my playground and playmates”. • Maintenance: No use of heroin for a long time; have made changes in my lifestyle to become a responsible person; helping others to stop drug use.

41. Stages of Change

42. What Stage Am I at? • You can select a behavior like diet or exercise and have participants describe what they are doing about it. Everyone has some area of life that they wish to change, even if it is just to earn a better salary, spend more time with their families or lose a few kilos. • Have a discussion in which a participant identifies a particular behavior that he/she wishes to change and invite others to comment on what stage the person is at.

43. Exercise: What Stage is this? • Try and identify the stage these persons are at: • Xing Xing is tired of everyone nagging her about her drug use: “Why don’t they just leave me alone! Don’t they understand that I feel better if I can just use a little heroin once in a while? It helps me relax, the same way some people like to drink alcohol. Why does heroin have to be illegal? It’s not fair!”

44. (Xing Xing is pre-contemplation) • Shao Hwa is really proud of himself. He has not used any heroin for two weeks and has stopped associating with those friends that he used drugs with in the past. He also avoids going to places where he used drugs. He is doing better a work now, has two new friends from work, and his family are happy to see him come home for dinner on time every night. He really hopes he can stay off drugs forever.

45. (Shao Hwa is action.) • Jia Ming has been in the DRC for two months now. He didn’t really think he needed to come here. “After all, I didn’t use heroin every day!” Lately, he has begun to see that he is similar to many of the other addicts in the way he used heroin. “Maybe I am on the same road as some of these hard-core addicts? Is it possible I will end up with serious addiction like them if I continue using heroin?”

46. (Jia Ming is contemplation) • Hong Ru left the DRC two years ago resolving to never use heroin again. About two months after leaving he DRC he slipped once and used some heroin he found in his closet. However, the next day he woke up horrified about this and called a supportive friend to come and talk with him. Since then he has not used again. He continues to call that friend when he feels a need for help. He has had perfect attendance at work and his boss told him how pleased he is with his progress. He has changed his lifestyle completely, spending time with his family and a new set of friends, and he feels confident that he can stay off drugs.

47. Group Discussion about Stages • (Hong Ru is maintenance) • Try and draw out participants to discuss where they are at in the stages. • Ask for them to share their lists of pros and cons (previous homework assignment) and how they feel about them. Has this led to motivation to really try to give up heroin? Have any taken action on their own to quit? (Being put in the DRC is not action!) • Some may be here due to legal authorities. How do they feel about being in treatment?

48. Summary and Review • We have seen that quitting heroin use (or any change in behavior) is a process. • First, you have to become convinced that heroin use is really a problem for you (and others) and that you need to change. ( move from pre-contemplation to contemplation) • Second, you have to make a commitment and plans to change. (preparation) • Third, you must take action to change your lifestyle and to prevent relapse. (action)

49. Change involves more than just not using heroin. It means taking care of yourself, learning the skills to prevent relapse, and living a responsible life. • Participation in this recovery program and following the suggestions that you will hear is a good way to begin to make these changes.

50. Homework • Write down answers to this question : “What kinds of changes do you think you will need to make in your life (the way you think, feel and behave) in order to stay away from heroin?”