Exhibit 2-1DSM-III-R and DSM-IV Draft Criteria for AOD Dependence
DSM-III-R Criterion No.
DSM-IV Draft Criterion No.
Diagnostic Criterion (language from DSM-III-R)
No. 1
No. 3
AODs are often taken in larger amounts or over a longer period of time than the person intended.
No. 2
No. 4
The person has a persistent desire or has made one or more unsuccessful efforts to cut down or control AOD use.
No. 3
No. 5
The person spends a great deal of time in activities necessary to obtain, consume, or recover from AOD effect
No. 4
Deleted
The person experiences frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations at work, school, or home, or when AOD use is physically hazardous.
No. 5
6
Important social, occupational, or recreational activities are given up or reduced because of AOD use.
No. 6
7
AOD use continues despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by AOD use.
No. 7
1
There is evidence of marked tolerance: a need for markedly increased amounts of AODs to achieve intoxication or a desired effect, or markedly diminished effect with continued use of the same amount.
No. 8
2
Evidence of characteristic withdrawal symptoms.
No. 9
2
AODs are often taken to relieve or avoid withdrawal symptoms.
Exhibit 3-1Treatment Approach Similarities and Differences
Mental Health System
Dual Disorders Approach
Addiction System
Medications
Central to the management of severe disorders in acute, subacute, and long-term phases of treatment: antidepressants, antipsychotics, anxiolytics, mood stabilizers.
Central to the treatment of many patients with dual disorders. Caution is used when prescribing psychoactive, mood-altering medications.
Central for acute detoxification; less common for subacute phase. Few used during long-term treatment: disulfiram, naltrexone, methadone, and LAAM.
Therapeutic Confrontations
Minimal to moderate use, depending upon setting, patient, and problem. Not central to therapy.
Generally used, but use is modulated according to fragility of mental status.
Use by staffand peers is one of the central techniques in AOD treatment.
Group Therapy
Central to treatment.
Central to treatment.
Central to treatment.
12-Step Groups
Although historically underused, use is growing. Examples include: Emotions Anonymous, Obsessive-Compulsive Anonymous, and Phobics Anonymous.
Dual Disorders Anonymous groups not yet widespread. Use of 12-step groups for AOD problems is central, but actively psychotic or paranoid patients may not mix well in meetings. "Double Trouble" AA groups are becoming more numerous.
Use of 12-step groups is central to AOD treatment. Great availability. Examples include: Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous.
Other Self-Help Groups
Numerous national organizations. Growing numbers of local groups. Use depends upon availability and awareness. Examples include: Anxiety Disorders Association of America, National Depressive & Manic-Depressive Association, Recovery, Inc., and National Association of Psychiatric Survivors.
Use of self-help groups regarding AOD and mental health problems is increasing.
Numerous organizations and groups, often specialized. Examples include: Women for Sobriety, Rational Recovery, Secular Organizations for Sobriety, International Doctors in AA, Recovering Counselors Network, and Social Workers Helping Social Workers.
Adapted with permission from Evans, K., and Sullivan, J.M.
Step Study Counseling With the Dual Disordered Client.
Center City, Minnesota: Hazelden Educational Materials, 1990.
Exhibit 7-2 Step Work Handout For Patients With Borderline Personality Disorder
Step One: "We admitted we were powerless over alcohol-that our lives had become unmanageable."
Describe five situations where you suffered negative consequences as a result of drinking or using other drugs.
List at least five "rules" that you have developed in order to try to control your use of alcohol or other drugs. (Example: "I never drink alone.")
Give one example describing how and when you broke each rule.
Check the following that apply to you:
I sometimes drink or use other drugs more than I plan.
I sometimes lie about my use of alcohol or other drugs.
I have hidden or stashed away alcohol or other drugs so I could use them alone or at a later time.
I have had memory losses when drinking or using other drugs.
I have tried to hurt myself when drinking or using other drugs.
I can drink or use more than I used to, without feeling drunk or high.
My personality changes when I drink or use other drugs.
I have school or work problems related to using alcohol or other drugs.
I have family problems related to my use of alcohol or other drugs.
I have legal problems related to my use of alcohol or other drugs.
Give two examples for each item that you checked.
Step Two: "We came to believe that a Power greater than ourselves could restore us to sanity."
Give three examples of how your drinking or use of other drugs was insane. (One definition of insanity is to keep repeating the same mistake and expecting a different outcome.)
Check which of the following mistakes or thinking errors that you use:
Blaming
Lying
Manipulating
Excuse making
Beating up yourself with "I should have" statements
Self-mutilation (cutting on yourself when angry)
Negative self-talk
Using angry behavior to control others
Thinking "I'm unique."
Explain how each thinking error you checked above is harmful to you and others.
Give two examples of something that has happened since you stopped drinking or using other drugs that shows you how your situation is improving.
Who or what is your Higher Power?
Why do you think your Higher Power can be helpful to you?
Step Three: "Made a decision to turn our will and our lives over to the care of God as we understood Him."
Explain how and why you decided to turn your will over to a Higher Power.
Give two examples of things or situations you have "turned over" in the last week.
List two current resentments you have, and explain why it is important for you to turn them over to your Higher Power.
How do you go about "turning over" a resentment?
What does it mean to turn your will and life over to your Higher Power?
Explain how and why you have turned your will and life over to a Power greater than yourself.
Step Four: "Made a searching and fearless moral inventory of ourselves."
List five things you like about yourself.
Give five examples of situations where you have been helpful to others.
Give three examples of sexual behaviors related to your drinking or use of other drugs, which have occurred in the last 5 years, about which you feel bad.
Describe how beating yourself up for old drinking and other drug-using behavior is not helpful to you now.
List five current resentments you have, and explain how holding on to these resentments hurts your recovery.
List all laws you have broken related to your drinking and use of other drugs.
List three new behaviors you have learned that are helpful to your recovery.
List all current fears you are experiencing, and discuss how working the first three Steps can help dissolve them.
Give an example of a current situation you are handling poorly.
Discuss how you plan to handle this situation differently the next time the situation arises.
Adapted with permission from Evans, K., and Sullivan, J.M. Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.
Exhibit 7-3Recovery Model for the Treatment Of Borderline Personality Disorder
Stage
Indications
Goal
Interventions
I. Crisis
Behavior out of control; risk of harm to self or others; extreme withdrawal or intrusiveness
Safety and health through structure and support
Inpatient stay
Contracts for safety
Case manager or support groups
Identify triggers for relapse or stress to plan for crisis
Make daily or weekly schedule to structure time
II. Building
Routine attendance at therapeutic sessions, meetings, appointments; some ability to stay focused on here and now
Increasing coping skills and self-esteem
Develop an assets or accomplishments list
Positive self-talk and affirmations
Skills training in time management, assertiveness, and so on
III. Education
Expresses, exhibits increased self-efficacy
Reframe self-perceptions and history from victim to survivor
Read or debrief clinician-prescreened ACOA or incest-survivor literature
Classes on dysfunctional families, survivor issues
Written assignments on strengths and limitations of "survivor behaviors"
IV. Integration
Able to express feelings
Integrate past, present, and regulate thinking and actions behaviors
Art therapy, journal work, current feelings, thoughts, other expressive modalities
Grief and child-within work, marital, sex, or family therapy
Adapted with permission from Evans, K., and Sullivan, J.M.
Step Study Counseling With the Dual Disordered Client.
Center City, Minnesota: Hazelden Educational Materials, 1990.
The group facilitator will present thinking errors and then ask each group member to identify two thinking-error examples that apply to him or her and to choose one to focus on with group help.
Excuse making -- Excuses can be made for anything and everything. Excuses are a way to justify behavior. For example: "I drink because my mother nags me," "My family was poor," "My family was rich."
Blaming -- Blaming is an excuse to avoid solving a problem and is used to excuse behavior and build up resentment toward someone else for "causing" whatever has happened. For example: "They forced me to drink it!"
Justifying -- To justify an antisocial behavior is to find a reason to support it. For example: "If you can, I can," "I deserve to get high," "I've got 30 days clean."
Redefining -- Redefining is shifting the focus on an issue to avoid solving a problem. Redefining is used as a power play to get the focus off the person in question. For example: "I didn't violate my probation. The language is confusing and the order is full of typos."
Superoptimism -- "I think; therefore it is." Example: "I don't have to go to AA. I can stay sober on my own."
Lying -- There are three basic kinds of lies: (1) lies of commission -- making things up that are simply not true; (2) lies of omission -- saying partly what is so, but leaving out major sections, and (3) lies of assent -- pretending to agree with other people or approving of their ideas despite disagreement or having no intention of supporting the idea.
"I'm Unique" -- Thinking one is special and that rules shouldn't apply to one.
Ingratiating -- Being nice to others, and going out of one's way to act interested in other people, can be used to try to control situations or get the focus off a problem. Apple polishing.
Fragmented Personality -- Some people may attend church on Sunday, get drunk or loaded on Tuesday, and then attend church again on Wednesday. They rarely consider the inconsistency between these behaviors. They may feel that they have the right to do whatever they want, and that their behaviors are justified.
Minimizing -- Minimizing behavior and action by talking about it in such a way that it seems insignificant. For example: "I only had one beer. Does that count as a relapse?"
Vagueness -- This strategy is to be unclear and nonspecific to avoid being pinned down on any particular issue. Vague words are phrases such as: "I more or less think so," "I guess," "probably," "maybe," "I might," "I'm not sure about this," "it possibly was," etc.
Power Play -- This strategy is to use power plays whenever one isn't getting one's way in a situation. Examples include walking out of a room during a disagreement, threatening to call an attorney or report the group facilitator to higher-ups.
Victim Playing -- The victim player transacts with others to invite either criticism or rescue from those around him.
Grandiosity -- Grandiosity is minimizing or maximizing the significance of an issue, and it justifies not solving the problem. For example: "I was too scared to do anything else but sit," "I'm the best there is, so no one else can get in my way."
Intellectualizing -- Using an emotionally detached, data-gathering approach to avoid responsibility. For example, when faced with a positive urine drug screen the patient states: "When was the last time the laboratory had their equipment calibrated?" or "What is the percentage of error in this testing procedure?"
Adapted with permission from Evans, K., and Sullivan, J.M.
Step Study Counseling With the Dual Disordered Client.
Center City, Minnesota: Hazelden Educational Materials, 1990.
Step One: "We admitted we were powerless over alcohol -- that our lives had become unmanageable."
Give five examples of ways you have tried to control your use of chemicals and failed.
Give five examples of people you have tried and failed to control, and explain why your controlling behavior was unsuccessful (minimum of 150 words each).
Give five examples of situations not associated directly with drinking or using other drugs where you have tried to control things and failed (minimum of 100 words each).
Give two examples of people who currently have control over you, and explain how that is helpful to you (minimum of 100 words each).
Give ten examples of how your drinking and using other drugs caused you problems (minimum of 25 words each).
Give five examples of negative consequences that await you should you continue using or abusing alcohol or other drugs (minimum of 50 words each).
Step Two:"Came to believe that a Power greater than ourselves could restore us to sanity."
Repeating the same mistake over and over when you continually receive negative consequences is one definition of insanity. From the list below, identify your "mistakes" (place a check mark on the line next to each "mistake" that applies). Then, below the list, explain how each of these mistakes in your thinking has caused you problems.
Excuse making
Minimizing
Blaming
Intentionally being vague
Using anger and threats
Superoptimism
Using power plays
Playing the victim
Making fools of others
Love for drama and excitement
Assuming what others think and feel
Not listening to others and being closed-minded
Thinking "I'm unique"
Maintaining an "image"
Being ingratiating (kissing up)
Being grandiose
Lying: commission, omission, assent
List three people with whom you are angry and explain how they can be helpful.
List five people more powerful than you who can help you stay clean and sober. Explain why and how each person can help.
Who or what is your Higher Power?
Describe how this Higher Power can help you with your mistakes in thinking.
Step Three: "Made a decision to turn our will and our lives over to the care of God as we understood Him."
How did you decide that you needed to turn your will over to a Higher Power?
Why is it important for you to turn your will and life over to a Higher Power?
Explain how you go about "turning it over."
Give three examples of things you have had to "turn over" in the last week.
Give three examples of things you have yet to turn over and explain how and when you plan to do so.
What does it mean to "turn your will and life over to your Higher Power"?
Without displaying any thinking errors, explain how and why you have turned your will and life over to a Power greater than yourself.
Step Four: "Made a searching and fearless moral inventory of ourselves."
List any and all law violations you have committed regardless of whether or not you were caught for these crimes.
List every person you have a resentment against, and explain how this resentment is hurting you.
Give ten examples of sexual behavior you engaged in that was harmful to your partner, and explain the negative consequences to you of this behavior.
Give five examples of aggressive behavior (either verbal or physical) you have been involved in, and explain how it was hurtful to the other person and to you.
List five major lies you have told, and explain how that lying was hurtful to you.
List three lies you have told within the last 48 hours, and explain how this lying hurts your recovery program.
Adapted with permission from Evans, K., and Sullivan, J.M.
Step Study Counseling With the Dual Disordered Client.
Center City, Minnesota: Hazelden Educational Materials, 1990.
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