TABLE OF CONTENTS
Created by psychiatrist Dr. Kim Rosenthal, Outside-the-Box Recovery (OTB) fills a growing need for clinically oriented but outside-the-box drug and alcohol treatment approaches. It’s about relapse prevention and motivational interviewing. It’s also about illustrations, optimism, creativity, art, and the occasional joke. Why this mix? Because studies show that combining mainstream practice with joy and humor improves patient outcomes. If you are a drug and alcohol counselor looking for ways to better motivate clients… then you’re in the right place.
I was on-call at the hospital when I was asked to see a young girl with heroin addiction. The 13-year-old had used a dirty needle that caused a blood infection. Her heart reacted by swelling to an enormous size, and soon it wasn’t strong enough to support her body. So, there the teen sat on the hospital bed, skin pale, oxygen tubing on her face, her hands a coarse tremor. She was dying, and she was in a panic. I tried to calm the child, but what could I say? Everything will be okay? Focus on the moment? It was too late. The next morning the room was empty. One life over.
Drugs kill. In 2017, more than 11.4 million people died worldwide from substances of abuse, excluding tobacco. That’s one death every three seconds!1 How many people have died since you started reading this page? It’s staggering. These aren’t just statistics. They’re horrible diseases, devastated families, lost dreams, and avoidable deaths.
Avoidable? Yes, but not avoided. People still use. In 2019, 35 million globally needed treatment for drugs or alcohol, excluding tobacco, but only one in eight pursued help.2 Even fewer stuck with it. The relapse rate is high, underscoring a need to find new ways to treat substance use disorders.
Part of the challenge is motivation. Quitting is extremely difficult. Life is filled with consequences and burned bridges. The past is a dangerous place to go, and the future with all its unknowns can be downright scary. For many, it’s easier to keep using than give life a go without drugs and alcohol.
Recovery work isn’t easy either. Clients must dig deep and answer difficult questions. They must study themselves in detail, taking apart their thoughts and behaviors to better understand their vulnerabilities. They must explore guilt and forgiveness and how addiction has affected them.
When clients do seek treatment, mainstream approaches often fail them. Today’s recovery workbooks have something to offer, sure, but they tend to be bland. The narrative is dry and formal, offering lots of complicated terms, and each page looks the same as the last. There’s little to catch client interest. We try to convince our patients that recovery can be joyful, playful even, but where do they see it?
To complicate matters, most recovery workbooks don’t recognize clients’ cognitive state. People in early recovery have problems with memory and concentration; they might be brilliant, but drugs have injured their brains, and they need time to heal. They also complain of boredom, they lack motivation, and they’re often depressed and demoralized.
To promote motivation and make up for other cognitive deficits, OTB is friendly and humored and nonjudgmental. Complex topics are introduced in simple ways. Issues are explained using catchy scenarios but NO jargon. Plot twists keep things interesting. Answers frequently include multiple-choice options. Nonverbal interventions like art therapy help when words can’t be found. OTB is also intensely positive. “Call it attitude, a belief system, a self-fulfilling prophecy,” the author says. “When you write your hopes and dreams on paper, something happens. This list is precious. It holds your future, so treat it gently.”
Premise: The Right Combination
OTB is the first to combine mainstream treatment practices with creativity and fun. The author argues that both are needed to best care for our patients.
As a psychiatrist, Rosenthal practices standard-of-care medicine. Relapse prevention and motivational interviewing are common treatment modalities, and we use them because they are highly effective. Cognitive Behavioral Therapy, the Matrix Model, Assertive Communication, Interpersonal Skills, and Mindfulness are also vital to patient care. OTB is based on these traditional core modalities. They are the framework.
But we need more than mainstream modalities. In the age of post-COVID, where isolation and addiction are more rampant than ever, we desperately need evidence-based treatment options that are outside-the-box. That means narrative therapy. It also means creative writing, art therapy, mindful coloring, positive psychology, poetry therapy, and letter-writing. Why outside-the-box? As mentioned, research shows that combining mainstream care with these extra approaches increases treatment retention and lowers relapse rate. That means we can improve patient outcomes by supplementing mainstream care with optimism, creativity, art, and the occasional joke. These modalities don’t replace traditional treatment. They augment them.
The chart below provides examples of traditional and non-traditional treatment approaches. The take-home message? Combining different treatment modalities improves patient care.
Each OTB workbook invites the reader on an introductory journey into the world of sobriety. It walks alongside providers and their clients during difficult moments, offering a unique, friendly, and creative approach to a challenging task. Together book, counselor, and client figure out how to survive the devastation of addiction. But they laugh a bit and seek joy too. There’s room for play, even silliness. Recovery isn’t always filled with humor, but we need it, don’t we? Despite the tragedies, there’s hope. Over time, clients find joy in who they are, what they surround themselves with, and a future filled with potential. OTB stays with clinicians and their patients as they embark on this journey.
There are two OTB books available on Amazon:
- The OTB Recovery Workbook
- The Second OTB Recovery Workbook
Book One guides clients through relapse prevention and making life changes by way of psychoeducation, motivational interviewing, CBT, dialectical behavioral therapy (chain analysis), and goal-setting. The workbook helps bolster the reader against cravings and triggers. It also helps readers better understand the concept of a sober new identity. Concepts include getting past mistakes, making friends, and “what to do if you relapse.”
Like the first book in the series, the SECOND delves into relapse prevention: Urge management, handling triggers, and rewriting problem thoughts. However, the SECOND book leans more heavily on the Matrix Model than the first, and it includes new themes, like gratitude, mindfulness, journaling, creating a schedule, honesty, limit-setting, and self-worth.
Other worksheet topics include:
- Recognizing and getting past triggers
- Practicing mindfulness
- Soothing tough emotions
- Grieving the loss of addiction
- Understanding needs versus wants
- Changing how you speak
- Enhancing interpersonal skills
- Assertive communication
- Recognizing self-worth
- Dealing with unforgiveable mistakes
- Understanding trust
- Recognizing bad relationships
- Being a good friend
Each book features over 25 worksheets. Most are 2-5 pages in length and written to cover a 45-60 minute group or individual meeting. They can be presented in any order. You simply make copies and hand them to clients—then read aloud. Worksheets may be used as primary therapist-driven treatment or to augment other approaches.
How do creativity and fun fit into things? Each worksheet carries an element of creativity, be it through drawing, writing, a strange scenario, joke, or otherwise. For example, in Book One, the reader delves into their relationship with drug problems by writing a movie. They grieve the loss of addiction via a “Dear John” letter and start to replace their substance use with something worthwhile, a hope or dream that makes sober life worth it. They explore change via alter ego. In Book Two, a communication quiz promotes an understanding of assertiveness. A naïve alien puts relationship safety into perspective. Poetry is used as a safe outlet to explore the past. And the quotation “I’ve seen great things you wouldn’t believe” gives way to what the reader finds astounding in their own lives.
Using the Workbooks
The workbooks feature a Professional Section with recommendations for each handout, including supporting literature and discussion ideas. This is part of the Appendix. It helps to refer to this information before presenting a handout.
The OTB workbooks feature lots of empty space. There’s room for writing, drawing, and doodling. Unless the books are used virtually online, clients should do ALL exercises in writing. This shows they’re doing the work and keeps a running record of their progress, plus there’s something powerful and solid about writing things down. If they won’t write, their resistance is grist for the mill. Look for the source and help get them past it.
All handouts end with a “Reflection” section featuring several important questions. This brings the topic home, anchors important points, and can be a great platform for discussion.
Relapse Prevention Plan
Book One features a four-page relapse prevention plan. Consider introducing this early and reviewing as often as possible, ideally a few minutes at each session. Clients will rarely review the plan when tempted to use. Rather, they should create and internalize a plan for themselves, something they automatically remember when the occasion calls for it. Individuals can use the book’s plan as a template.
“Take-a-Break” worksheets are friendly, fun breaks from the hard work of recovery. They range from puzzles to coloring to letters from the future. These sheets can be used at the beginning or end of a session to fill in free time, as a good destressor, or as optional homework.
Both books are filled with quizzes. Occasionally, the questions and answers are found on the same page; if this is the case, consider asking your clients to fold the answers back until ready for review. Or they can simply cover them with a sheet of paper. Solutions to puzzles are found at the back of the book.
Rosenthal’s literature promotes a zest for sober living through inspiring, humored, and treatment relevant material. She has two books on Amazon, as well as a website featuring 120+ articles, videos on YouTube, and dozens of free handouts. You can also subscribe to this website to receive a free (abridged) copy of the STEP ONE booklet. There’s also a randomly generated newsletter that comes out when no one is watching. It features free stuff, latest news, and the occasional secret.
Kim Rosenthal, MD
“I absolutely love OTB! I have handed out worksheets as individual assignments for someone to work on if they are struggling
in a certain area. They grab my clients’ interest immediately
and their laughter breaks down walls.”
Karin Kaufmann, ARS, ACIT, CAPRC-II
“I love Dr. Rosenthal’s materials. I have been in recovery
for 20 years and teaching groups for 18. This is the best
teaching tool I have ever used. My clients and I are grateful.”
“I stumbled on Dr. Rosenthal’s website a couple years ago.
The therapists in our group looooovvee the handouts
and use them regularly. The owner of the company loved
it so much that she purchased a book for each of the offices
under her tutelage. We are looking forward to the next
book. Thank you so much for all you do!!!”
Sheri Cannon, LPN
“Once again, Rosenthal has knocked it out of the park.
I absolutely love her work. I use it all the time, and my clients
are very receptive. It’s truly a breath of fresh air. I adore her
approach with humor and pictures, and the information is
very thorough. She asks questions to get clients thinking
about their lives and choices.”
Charlotte Prather, SUDC
“I have handed out worksheets as individual assignments
for someone to work on if they are struggling in a certain
area. They grab my clients’ interest immediately and their
laughter breaks down walls.”
Karin Kaufmann, ARS, ACIT, CAPRC-II
“I love the concept of this book. I’m able to photocopy worksheet pages for my clients then provide them with coloring pencils to use in conjunction with the work in the handout. This is a great and valuable resource!”
Lisa Ackland, LLMSW, DP-CAADC