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The CENAPS® Model of Relapse Prevention Therapy (CMRPT®)

Terence T. Gorski
1. OVERVIEW, DESCRIPTION, AND RATIONALE
1.1 General Description of Approach
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The CENAPS® Model of Relapse Prevention Therapy (CMRPT®) is a comprehensive method for preventing chemically dependent clients from returning to alcohol and other drug use after initial treatment and for early intervention should chemical use occur.

1.2 Goals and Objectives of Approach

The five primary goals of the CMRPT are to:

  1. Assess the global lifestyle patterns contributing to relapse by completing a comprehensive self-assessment of life, addiction, and relapse history.

  2. Construct a personalized list of relapse warning signs that lead the relapser from stable recovery back to chemical use.

  3. Develop warning sign management strategies for the critical warning signs.

  4. Develop a structured recovery program that will allow clients to identify and manage the critical warning signs as they occur.

  5. Develop a relapse early intervention plan that will provide the client and significant others with step-by-step instructions to interrupt alcohol and other drug use should it recur.

1.3 Theoretical Rationale/Mechanism of Action

The CMRPT is a clinical procedure that integrates the disease model of chemical addiction and abstinence-based counseling methods with recent advances in cognitive, affective, behavioral, and social therapies. The method is designed to be delivered across levels of care with a primary focus on outpatient delivery systems. The CMRPT consists of five primary components:

  1. Assessment.

  2. Warning sign identification.

  3. Warning sign management.

  4. Recovery planning.

  5. Relapse early intervention training.

Cognitive, affective, and behavioral therapy principles are targeted to accomplish the specific goals of each CMRPT component.

The CMRPT incorporates standard and structured group and individual therapy sessions and psychoeducational (PE) programs that focus primarily on these five primary goals. The treatment is holistic in nature and involves clients in a structured program of recovery activities. Willingness to comply with the recovery structure and actively participate within the structured sessions is a major factor in accepting clients for treatment with this model.

1.4 Agent of Change

The primary agent of change is the completion of a structured clinical protocol in a process-oriented interaction among the client, the primary therapist or counselor, and members of the therapy groups.

1.5 Conception of Drug Abuse/Addiction, Causative Factors

The CMRPT has been under development since the early 1970s (Gorski 1989a). It integrates the fundamental principles of Alcoholics Anonymous (AA) with professional counseling and therapy to meet the needs of relapse-prone clients.

The CMRPT can be described as the third wave of chemical addiction treatment. The first wave was the introduction of the 12 steps of AA. The second wave was the integration of AA with professional treatment into a model known as the Minnesota Model. The CMRPT, the third wave in chemical addiction treatment, integrates knowledge of chemical addiction into a biopsychosocial model and 12-step principles with advanced cognitive, affective, behavioral, and social therapy principles to produce a model for both primary recovery and relapse prevention (RP).

The CMRPT is based on a biopsychosocial model, which states that chemical addiction is a primary disease or disorder resulting in abuse of and addiction to mood-altering chemicals. Long-term use of mood-altering chemicals causes brain dysfunction that disorganizes personality and causes social and occupational problems.

The CMRPT is based on the belief that total abstinence plus personality and lifestyle change are essential for full recovery. People raised in dysfunctional families often develop self-defeating personality styles (AA calls them character defects) that interfere with their ability to recover. Addiction is a chronic disease that has a tendency toward relapse. Relapse is the process of becoming dysfunctional in recovery, which ends in physical or emotional collapse, suicide, or self-medication with alcohol or other drugs. The CMRPT incorporates the roles of brain dysfunction, personality disorganization, social dysfunction, and family-of-origin problems to the problems of recovery and relapse.

Brain dysfunction occurs during periods of intoxication, short-term withdrawal, and long-term withdrawal. Clients with a genetic history of addiction appear to be more susceptible to this brain dysfunction. As the addiction progresses, the symptoms of this brain dysfunction cause difficulty in thinking clearly, managing feelings and emotions, remembering things, sleeping restfully, recognizing and managing stress, and psychomotor coordination. The symptoms are most severe during the first 6 to 18 months of sobriety, but there is a lifelong tendency of these symptoms to return during times of physical or psychosocial stress.

Personality disorganization occurs because the brain dysfunction interferes with normal thinking, feeling, and acting. Some of the personality disorganization is temporary and will spontaneously subside with abstinence as the brain recovers from the dysfunction. Other personality traits will become deeply habituated during the addiction and will require treatment to subside.

Social dysfunction, which includes family, work, legal, and financial problems, emerges as a consequence of brain dysfunction and resultant personality disorganization.

Addiction can be influenced, not caused, by self-defeating personality traits that result from being raised in a dysfunctional family. Personality is the habitual way of thinking, feeling, acting, and relating to others that develops in children and is unconsciously perpetuated in adult living. Personality develops as a result of an interaction between genetically inherited traits and family environment.

Being raised in a dysfunctional family can result in self-defeating personality traits or disorders. These traits and disorders do not cause the addiction to occur. They can cause a more rapid progression of the addiction, make it difficult to recognize and seek treatment during the early stages of the addiction, or make it difficult to benefit from treatment. Self-defeating personality traits and disorders also increase the risk of relapse. As a result, family-of-origin problems need to be appropriately addressed in treatment.

The relapse syndrome is an integral part of the addictive disease process. The disease is a double-edged sword with two cutting edges—drug-based symptoms that manifest themselves during active episodes of chemical use and sobriety-based symptoms that emerge during periods of abstinence. The sobriety-based symptoms create a tendency toward relapse that is part of the disease itself. Relapse is the process of becoming dysfunctional in sobriety because of sobriety-based symptoms that lead to renewed alcohol or other drug use, physical or emotional collapse, or suicide. The relapse process is marked by predictable and identifiable warning signs that begin long before alcohol and other drug use or collapse occurs. RP therapy teaches clients to recognize and manage these warning signs and to interrupt the relapse progression early and return to positive progress in recovery.

The CMRPT conceptualizes recovery as a developmental process that goes through six stages. The first stage is Transition, where clients recognize that they are experiencing alcohol- and other drug-related problems and need to pursue abstinence as a lifestyle goal so they can resolve these problems. The second stage is Stabilization, where clients recover from acute and postacute withdrawal and stabilize their psychosocial life crisis. The third stage is Early Recovery, where clients identify and learn how to replace addictive thoughts, feelings, and behaviors with sobriety-centered thoughts, feelings, and behaviors. The fourth stage is Middle Recovery, where clients repair the lifestyle damage caused by the addiction and develop a balanced and healthy lifestyle. The fifth stage is Late Recovery, where clients resolve family-of-origin issues that impair the quality of recovery and act as long-term relapse triggers. The sixth stage is Maintenance, where clients continue a program of growth and development and maintain an active recovery program to ensure that they do not slip back into old addictive patterns.

The CMRPT is based on a balanced biopsychosocial model that recognizes three primary psychological domains of functioning and three primary social domains of functioning. Each of these domains is considered equally important.

The primary psychological domains are:

  1. Thinking.

  2. Feeling.

  3. Acting.

The primary social domains are:

  1. Work.

  2. Friendship.

  3. Intimate relationships.

The clinical goal is to help clients achieve competent functioning within each of these domains.

Clients usually have a preference for one psychological domain and one social domain. These preferred domains become overdeveloped while the others remain underdeveloped. The goal is to reinforce the skills in the overdeveloped domains while focusing the client on building skills in the underdeveloped domains. The goal is to achieve healthy, balanced functioning.

Imagery is viewed as a primary mediating function between thinking, feeling, and acting. The CMRPT makes extensive use of both guided imagery for mental rehearsal and spontaneous imagery for cognitive and emotional integration work.

2. CONTRAST TO OTHER COUNSELING APPROACHES
2.1 Most Similar Counseling Approaches

The CMRPT is an applied cognitive-behavioral therapy program. It is similar to Rational Emotive Therapy and Beck's Cognitive Therapy Model. The primary difference is that the CMRPT applies cognitive-behavioral therapy principles directly to the problem, teaching chemically dependent clients how to maintain abstinence from alcohol and other drugs.

The CMRPT heavily emphasizes affective therapy principles by focusing on the identification, appropriate labeling, and communication and resolution of feelings and emotions. The CMRPT integrates a cognitive and affective therapy model for understanding emotions by teaching clients that emotions are generated by irrational thinking (cognitive theory) and are traumatically stored or repressed (affective theory). Emotional integration work involves both cognitive labeling and expression of feelings and imagery-oriented therapies designed to unrepress memories. The model relies heavily on guided and spontaneous imagery and sentence completion and repetition work designed to create corrective emotional experiences.

This model is also similar to and has been heavily influenced by the Cognitive-Behavioral Relapse Prevention Model developed by Marlatt and Gordon (George 1989; Marlatt and Gordon 1985). The major difference is that the CMRPT integrates abstinence-based treatment and has greater compatibility with 12-step programs than the Marlatt and Gordon model.

The CMRPT integrates well with a variety of cognitive, affective, behavioral, and social therapies. Its primary strength is that it allows clinicians from varying clinical backgrounds to apply their skills directly to RP. As a result, it is ideal for use by a multidisciplinary treatment team.

2.2 Most Dissimilar Counseling Approaches

The CMRPT is most dissimiliar to the following types of therapy:

  1. Therapies that view chemical addiction as a symptom of an underlying mental or psychological problem.

  2. Controlled drinking or self-control training that promotes controlled or responsible use for chemically dependent clients who have exhibited physical and psychological addiction to alcohol and other drugs.

  3. Nondirective or client-centered approaches.

  4. Any form of therapy that isolates or exclusively focuses on any single domain of physical, psychological, or social functioning to the exclusion of the other domains of functioning.

The CMRPT is very different from rigid cognitive therapy models, which believe the challenge of irrational thoughts will bring automatic emotional integration, or rigid affective therapy models, which believe that emotional catharsis work will automatically result in spontaneous cognitive and behavioral change.

FORMAT

The CMRPT uses a standard session format for problem solving group therapy, individual therapy, and PE.

3.1 Modalities of Treatment

The CMRPT uses a standard session model of problem solving group therapy consisting of group rules, group responsibilities, a standard group format, and a problem solving group counseling format.

3.1.1 Group Rules.

The following rules are used as part of the problem solving group process.

  1. Group members can say whatever they want, whenever they want. Silence is not a virtue in the group and in fact can be harmful to a group member's recovery.

  2. Group members can refuse to answer any questions or participate in any activity other than basic group responsibilities. Group members cannot be forced to participate, but they have the right to express their feelings about any member's silence or any member's choice not to get involved.

  3. What is said and takes place in the group stays among the members. Only counselors can consult with fellow counselors to offer members better, more effective treatment.

  4. No swearing, putting down, fighting, or threats of violence are permitted. The threat of violence is considered as good as the act.

  5. No dating, romantic involvement, or sexual involvement among the members of the group is permitted, as these activities can sabotage the treatment of either one or both. If such involvement does begin, it should immediately be brought to the attention of a counselor.

  6. Anyone who decides to leave the group must inform the group (in person) prior to departure.

  7. Group members should be on time for the 2-hour sessions and should not plan to leave before the session ends. No smoking, eating, or drinking is permitted.

3.1.2 Group Responsibilities.

Group members agree to fulfill the following basic group responsibilities:

  1. Offer their reaction at the beginning of each session.

  2. Volunteer to work on a personal issue in each group session.

  3. Complete all assignments and report to the group on what was learned.

  4. Listen to other group members when they present problems.

  5. Ask questions to help clarify the problem or proposed solution.

  6. Offer feedback about the problem and the group member presenting the problem.

  7. When appropriate, share personal experiences with similar problems.

  8. Complete the closure exercise by reporting to the group what was learned in the session and what could be done differently as a result of what was learned.

3.1.3 problem solving Group Counseling Format.

The group therapy sessions follow a standard eight-part group therapy protocol. The first and last steps of the protocol (preparation and debriefing) are attended by the therapy team only. The other steps in the protocol take place during the actual group therapy session.

  1. Preparatory session. The session begins by reviewing clients' treatment plans, goals, and current progress in implementing treatment interventions. Each client's progress is reviewed, and an attempt is made to predict the assignments and problems that the client will present.

  2. Opening procedure (5 minutes). The counselor sets the climate for the group, establishes leadership, and helps clients warm up to the group process.

  3. Reactions to last session (15 minutes). Each group member describes his or her thoughts and feelings about the session and identifies three persons who stood out from that session and why they were remembered.

  4. Report on assignments (10 minutes). Exercises that clients are working on to identify and manage relapse warning signs or deal with other problems related to RP are shared or are completed during the session; other assignments are completed between sessions.
  5. Immediately following each member's reactions, the counselor asks all group members who have received assignments to briefly answer the following questions:

    • What was the assignment and why was it assigned?

    • Was the assignment completed and, if not, what happened when it was tried?

    • What was learned by completing the assignment?

    • What feelings and emotions were experienced while working on the assignment?

    • Were there any issues that required additional work by the group?

    • Is there anything else that needs to be worked on in group today?

  6. Setting the agenda (3 minutes). After all assignments have been shared, the group counselor identifies those group members who want to work and announces their names and the order in which they will present. Those who do not present their work during this session are first on the agenda in the next one. It is best to plan on no more than three members presenting in any group session.

  7. problem solving group process (70 minutes). Clients present issues to the group, clarify them through group questioning, receive feedback from the group and (if appropriate) from the counselor, and develop assignments for continued progress.

  8. Closure exercise. When about 15 minutes remain in the group session, the counselor asks each member to share the most important thing he or she learned in group and what could be done differently as a result of what was learned.

  9. Debriefing session. This session reviews the client's problems and progress, improves the group skills of the counselor, and helps prevent counselor burnout. It is especially helpful if this can be done with other counselors running similar groups. A brief review of each client is completed, outstanding group members and events are identified, progress and problems are discussed, and the personal feelings and reactions of the counselor are reviewed.

3.2 Ideal Treatment Setting

The ideal setting for the CMRPT is a primary outpatient program made up of a minimum of 12 group sessions, 10 individual therapy sessions, and 6 PE sessions administered over a period of 6 weeks. Clients with literacy problems, cognitive impairments, or mental and personality disorders usually require longer lengths of stay to complete the therapeutic objectives. Clients are detoxified in a variable-length-of-stay inpatient or residential facility. During detoxification, the client is stabilized, assessed, and motivated to continue with the CMRPT in a primary outpatient program. After completing the primary outpatient program, the client is transferred to an ongoing group and individual therapy program (four group sessions and two individual sessions per month) to implement the warning sign identification and management procedures and update the RP plan based on experiences in recovery.

Brief readmission (3 to 10 days) for residential stabilization may be required should clients return to chemical use, develop severe warning signs that render them out of control and at risk, or put them at high risk of returning to chemical use.

The CMRPT is well adapted for use with chemically dependent criminal offenders in the criminal justice system who have antisocial personality disorders. The CMRPT is most effective when integrated with the cognitive-behavioral method for identifying and managing criminal thinking. In such programs, the model needs to be initiated in residential treatment during the last 12 weeks of incarceration, continued in a halfway setting for a period of 3 to 6 months, and then continued in a primary outpatient program for a minimum of 2 years.

3.3 Duration of Treatment

The CMRPT can be administered in a variety of settings over a variable number of sessions.

3.3.1 Residential Rehabilitation Model.

The CMRPT was originally used in 28-day residential programs and administered over a course of 20 90-minute group therapy sessions, 12 individual therapy sessions, and 20 90-minute PE sessions. The protocol was supplemented by involvement in self-help groups. Clients were then transferred into a 90-day outpatient program consisting of 12 90-minute group therapy sessions (once per week) and six 60-minute individual therapy sessions (twice per month). This was supplemented by attendance at 24 12-step meetings and 6 RP support groups.

3.3.2 Primary Outpatient Program.

The CMRPT was later used in an intensive outpatient program consisting of 10 individual therapy sessions, 12 group therapy sessions, 6 PE groups, and attendance at 6 12-step meetings and 6 RP support groups. Clients were then transferred to a 90-day warning-sign identification management group consisting of 12 group therapy sessions and 6 individual therapy sessions and continued involvement in 12-step meetings and RP support groups.

3.3.3 PE Programs.

The CMRPT has been delivered as a PE program consisting of between 8 and 24 education sessions ranging from 1-1/2 to 3 hours per session. Motivated clients with adequate reading and writing skills have been able to benefit from involvement in these programs. These PE programs are usually integrated with the residential or primary outpatient programs.

3.4 Compatibility With Other Treatments

The CMRPT is compatible with a variety of other treatments, including 12-step programs; family therapy; and a variety of cognitive, affective, and behavioral therapy models.

The CMRPT works well with court diversion programs and employee assistance programs (EAPs). A special occupation RP protocol has been developed for use in conjunction with EAP referrals. This protocol focuses on identifying on-the-job relapse warning signs and teaching EAP counselors and supervisors how to intervene on those warning signs as part of the supervision and corrective discipline process.

A special protocol for working with chemically dependent criminal offenders has also been developed. This model integrates the treatment of criminal thinking and antisocial personality disorders with chemical addiction recovery and RP methods. The protocol integrates a biopsychosocial model, a developmental model of recovery, and a relapse warning sign model designed for clients with antisocial personality disorders and other Cluster B personality disorders. This model is designed to be administered in long-term treatment as the client moves from incarceration to halfway house to intensive outpatient to ongoing outpatient settings over a period of 1 to 5 years.

Specialty application of the CMRPT has been developed for clients with posttraumatic stress disorder (PTSD) resulting from child physical and sexual abuse (Trotter 1992).

Since the protocol identifies and develops management strategies for a variety of problems that cause relapse, coexisting mental disorders and lifestyle problems are often identified and treated in conjunction with RP therapy.

A special protocol for family therapy was developed to facilitate family involvement in warning sign identification and management. Johnson-style family intervention methods were adapted for use in a family-oriented relapse early intervention plan.

3.5 Role of Self-Help Programs

Because it is based on a disease model and abstinence-based treatment, the CMRPT is designed to be compatible with 12-step programs. A special interpretation of the 12 steps was developed to help clients relate 12-step program involvement to RP principles.

Special self-help support groups called Relapse Prevention Support Groups (Gorski 1989b) were developed to encourage clients to continue in ongoing warning sign identification and management.

4. COUNSELOR CHARACTERISTICS AND TRAINING

The CMRPT is designed to be implemented at one of three levels: basic research prevention therapy (RPT), recovery-oriented RPT, and psychotherapy-oriented RPT. Different credentials are recommended for practice at each of these three levels.

4.1 Educational Requirements

Professionals with a variety of credentials—ranging from nondegreed certified addiction counselors to doctoral-level clinical psychologists—have been trained and successfully practice the CMRPT. The more training a counselor has in chemical addiction treatment and cognitive behavioral therapy, the more effective he or she is in utilizing the CMRPT.

4.2 Training, Credentials, and Experience Required

Many counselors and therapists are able to use CMRPT techniques effectively after reading Staying Sober: A Guide for Relapse Prevention (Gorski and Miller 1986) and the Staying Sober Workbook (Gorski 1988), which outline the basic theories and clinical procedures. It is recommended that counselors become competency certified by completing a 6-1/2-day training course and competency certification procedure.

4.3 Counselor's Recovery Status

Whether or not a counselor is in recovery is irrelevant to the delivery of the CMRPT. It is important that the counselor believe in abstinence-based treatment, avoid the use of harsh psychonoxious confrontation, have good communication skills and well-developed helping characteristics, and be a role model for a functional and sober lifestyle. The capacity for empathy with the relapse-prone client is essential.

4.4 Ideal Personal Characteristics of Counselor

Ideally, the RP counselor would be a recovering chemically dependent person with a past history of relapse who recovered using RP therapy methods, currently has over 5 years of uninterrupted sobriety, and has a master's degree or above with advanced training in cognitive, affective, and behavioral therapy techniques.

4.5 Counselor's Behaviors Prescribed

RP counselors are trained to enter into a collaborative relationship with their clients. Supportive and directive approaches that avoid harsh, psychonoxious confrontation are required. A foundation of good basic counseling and therapy skills is required. Additional training in the procedures of the CMRPT is essential.

4.6 Counselor's Behaviors Proscribed

RP counselors are discouraged from becoming harshly confrontational. Confrontation is designed to be directive and supportive, with the counselor pointing out self-defeating ways of thinking and acting while advocating the basic integrity of the client. Any form of confrontation that disempowers the client or attacks the client's core integrity as a human being is seen as inappropriate.

The model is consistent with the professional code of ethics for counselors and therapists in that it proscribes personal relationships and romantic or sexual involvement with clients.

4.7 Recommended Supervision

Supervision should be maintained on a regular basis and should combine both group supervision and individual supervision. Supervision should be problem focused and address issues of how to adapt the standard protocols to meet the individual needs of clients.

Personal issues of the counselor only become a focus of the supervision when personal characteristics begin to interfere with the use of the effective use of the standard protocols. Should this occur, the supervisor generally addresses the immediate problem interfering with treatment and develops a plan with the counselor to modify his or her approach. Should problems continue, the counselor is referred to an EAP or a private therapist to resolve the private issues that are interfering with the therapy processes.

5. CLIENT-COUNSELOR RELATIONSHIP
5.1 What Is the Counselor's Role?

The counselor plays the role of educator, collaborator, and therapist. The counselor has a prescribed series of RP exercises to use that guide a client through the context of group therapy and individual therapy sessions and structured PE programs. The goal is to explain each procedure or exercises, assign appropriate homework exercises, and process the results of the homework in group and individual therapy sessions. The aim is to help clients recognize and manage relapse warning signs by facilitating insight, catharsis, and behavior change.

5.2 Who Talks More?

The client is expected to play an active role in the RP therapy process. The client is given a series of assignments and is expected to actively process those assignments in group and individual therapy sessions. Many of the assignments involve peer support and sharing of information and experiences.

5.3 How Directive Is the Counselor?

The counselor is very directive in establishing the agenda and maintaining compliance with standard clinical procedures. It is the counselor's job to adapt the standard procedures to meet clients' needs. The counselor expects clients to learn basic therapeutic skills and use them in the counseling process. Although the counselor directly enforces the use of a clinical procedure or process, he or she is careful to allow clients to provide the content for the therapy. Special care needs to be taken not to project problems on the clients that they do not have.

6. TARGET POPULATIONS
6.1 Clients Best Suited for This Counseling Approach

Clients who do well with the CMRPT have average or above-average conceptual skills and eighth grade or better reading and writing skills but no learning disabilities, severe cognitive impairments, active impulse control disorders, or other diagnosis that interferes with the ability to participate in a structured cognitive-behavioral therapy program. In addition, they have been detoxified.

6.2 Clients Poorly Suited for This Counseling Approach

Clients who do not do well with the CMRPT are below average in conceptual level; have significant literacy problems; and have organic impairments, learning disabilities, or other mental disorders that interfere with their ability to respond to cognitive-behavioral therapy interventions.

6.3 Adaptation to Special Populations

The CMRPT is adaptable to the needs of a variety of client populations. The techniques have been used successfully with cocaine addicts, adolescents, revolving-door detox clients, physically and sexually abused men and women, criminal justice system populations, and clients with dual diagnosis. The basic protocol, however, must be adapted to meet the needs of the specialty client group.

7. ASSESSMENT

Clients undergo a comprehensive screening interview to determine their appropriateness for the CMRPT. A comprehensive analysis of the client's presenting problems, life and addiction history, and recovery and relapse history are then completed. A standard checklist of relapse warning signs is used to initiate warning sign identification and management.

8. SESSION FORMAT AND CONTENT
8.1 Format for a Typical Session

The CMRPT uses problem solving group therapy, individual therapy, and PE session formats. Clients are asked to make a commitment to a structured recovery program, to look at self-help groups, and to consider holistic health approaches, including diet, exercise, and social and spiritual activities.

8.2 Several Typical Session Topics or Themes

Therapy is primarily directed toward the identification and management of relapse warning signs. This model consists of 37 structured exercises that have been developed over 20 years of clinical experience. These are presented in detail in The Staying Sober Workbook. The primary focus of all sessions is to guide clients in completing these exercises, which result in a personalized list of relapse warning signs (the unique personal problems that lead the client back to alcohol and other drug use) and warning sign management strategies (concrete situational and behavioral coping strategies for managing the warning signs without returning to chemical use).

Clients are involved in a structured recovery program that provides holistic health maintenance for a healthy and sober lifestyle. Breaks in the recovery program are viewed as critical relapse warning signs, and immediate intervention is initiated when they become apparent.

Other problems in recovery include situational life problems and symptoms of dual diagnosis, which are viewed as relapse warning signs. Management strategies are developed that provide direct treatment for these conditions and disorders as part of the RP therapy plan.

Clients with dual disorders are treated in specialty RP programs with other relapse-prone chemically dependent clients with the same disorder, or they are referred for concurrent treatment in close coordination with RP therapy.

8.3 Session Structure

The CMRPT program is highly structured; compliance with the basic therapeutic structures is strongly emphasized and is a prerequisite for involvement.

8.3.1 Group Therapy Format.

Group therapy participants learn a standard problem solving group process that guides problem resolution. The seven-step process is:

  1. Identify problems. Have clients ask questions to identify what is causing difficulty. What is the problem?

  2. Clarify problems. Clients are encouraged to be specific and complete. Is this the real problem, or is there a more fundamental problem?

  3. Identify alternatives. Have clients list alternatives on paper so they can readily see them. Then have the group come up with a list of at least five possible solutions. This gives clients more of a chance of choosing the best solution and gives them alternatives if their first choice does not work. What are some options for dealing with the problem?

  4. Project consequences. Have clients project implications of each alternative. What are the best, worst, and most likely outcomes that could be achieved by using each alternative solution?

  5. Make a decision. Have the group ask which option offers the best outcome and seems to have the best chance for success. Have the group then make a decision based on the alternatives.

  6. Take action. Once the group decides on a solution to the problem, they need to plan how they will carry it out. The plan should answer the question, What can be done about it?

  7. Follow up. Ask clients to carry out their plans and report back on their progress.

8.3.2 Individual Therapy Format.

The goal of individual therapy is to assist the client in identifying and clarifying problems and preparing to present them in group. A standard agenda is used.

  • Reactions to previous session. The counselor discusses the client's reactions to the previous individual and group therapy sessions.

  • Sobriety check. The counselor asks the client if he or she has stayed clean and sober, experienced any cravings or urges to use alcohol or other drugs, and attended and participated in all scheduled recovery activities.

  • Clinical work. The issues that the client is currently working on are reviewed in depth. During this part of the session the counselor presents and identifies problems, clarifies the work to be done, and motivates the client to present issues in group. If intense cathartic work is required, this is usually done in individual sessions rather than in group therapy sessions.

  • Preparation for group. Each client rehearses how he or she will present issues to the group. The primary goal is to prepare and support each client in efficiently working on issues in group. Group is viewed as the primary or central treatment modality with individual therapy playing a supportive role.

8.3.3 PE Group Format.

A standard PE group format is used that is based on proven adult learning principles.

  • Pretest. Participants are given a pretest to determine their knowledge level at the beginning of the sessions.

  • Lecture. A brief lecture is given describing the basic information for the class.

  • Group exercise. A group learning exercise is completed that requires all class members to become actively involved in using the material they heard in the lecture.

  • Posttest. Participants are given a posttest to see if they changed any of their answers as a result of the sessions.

  • Discussion. The counselor facilitates a group discussion and question-and-answer session to review the correct answers to the test.

The lecture topics used relate to four general areas:

  1. Biopsychosocial disease process. The biopsychosocial symptoms of chemical addiction and other behavioral health disorders are explained. This topic is designed to help clients recognize and accept their chemical addiction and dual disorders and make a commitment to recovery.

  2. Developmental recovery process. The developmental stages of recovery from chemical addiction and other behavioral health disorders are explained. The educational exercises focus on helping clients identify their particular stage of recovery and develop appropriate recovery plans. The topic is designed to help clients recognize their current stage of recovery, develop an immediate recovery plan, and anticipate future long-term recovery needs.

  3. The relapse process. The common warning signs that precede relapse are explained, as are methods to identify and intervene on warning signs without using alcohol or other drugs. The process of relapse, early intervention, and rapid stabilization is also explained. This topic is designed to help clients recognize their personal relapse warning signs and to develop RP and early intervention plans.

  4. Accessing recovery resources. Recovery resources, such as ongoing counseling, 12-step programs, Rational Recovery groups, and other sobriety support programs are explained. The goal is to teach clients how to build a structured long-term recovery program based on inexpensive and readily available community resources.

The CENAPS Corporation publishes a comprehensive guide to recovery education called The Staying Sober Recovery Education Modules. This manual contains detailed education sessions following the processes described earlier for each vital educational area.

8.4 Strategies for Dealing With Common Clinical Problems

The CMRPT relies heavily on structured program procedures. The process is initiated with client contracting, and a commitment is secured for attendance, punctuality, and willingness to comply with client responsibilities and active participation within the session structures. Clients who refuse to make such a commitment are viewed as poor candidates for the program and are not admitted for therapy.

In spite of this initial participation contract, routine problems do develop in treatment. All such problems are viewed as relapse warning indicators because they place the client's ongoing therapy at risk and, hence, increase the risk of relapse. The following issues are promptly dealt with as critical issues.

8.4.1 Lateness.

Clients are expected to be on time for sessions. Following is the standard procedure for dealing with lateness. Prior to entering group, clients contract to be on time for all sessions.

  1. If clients arrive late within the first 15 minutes of group (prior to the end of reactions), they are allowed to stay for that group session only if they agree to work on the issues that prompted the lateness.

  2. If clients are more than 15 minutes late for the first session, or if they are late for the second session, they are not allowed in group and must have an individual session with their therapist before being allowed back in group, where they must demonstrate that they have identified and resolved the issue(s) related to lateness.

  3. If clients are late on three or more occasions during any 12-week period, they are discharged from the group.

Similar no-nonsense procedures are applied to individual therapy. Only extremely credible excuses are accepted for absence or tardiness and only if there is no pattern of absence or tardiness.

8.4.2 Missed Sessions.

Clients are expected to attend all therapy sessions. The only excuse for absence is extreme documented illness (with a physician's note) and serious documented life crisis, such as a death in the family. All excused absences must be called in and be approved in advance by the counselor. Any pattern of three or more absences within any 12-week period is grounds for dismissal regardless of the reasons.

8.4.3 Chemical Relapse and Intoxicated Clients.

Intoxicated clients are not allowed to remain in group. If the group counselor suspects a client is intoxicated, the client is asked to verify it in group. If the client denies intoxication but his or her behavior gives reasonable cause to believe alcohol or other drugs have been used, the client is immediately given a breath test for alcohol and a urine drug screen.

Appearing intoxicated for session is viewed as a chemical relapse. The client is immediately removed from group because he or she cannot benefit from therapy when under the influence of mood-altering drugs. An immediate screening appointment is established, and the client is admitted to a stabilization program at the appropriate level of care to deal with withdrawal.

Procedures for dealing with chemical relapses follow.

The counselor deals with relapse to alcohol and other drug use as a medical issue requiring stabilization and treats the client professionally. Anger at the client is viewed as a maladaptive countertransference response, which the counselor needs to resolve in clinical supervision.

If a client refuses to follow recommendations for stabilization, he or she is terminated from treatment. If the client follows stabilization recommendations, he or she is evaluated at the end of stabilization and referred to appropriate ongoing treatment. This usually involves being returned to the same therapist and outpatient group to process the relapse and use material learned to update and revise RP strategies.

In short, relapse is viewed as part of the disease and is dealt with nonjudgmentally and nonpunitively. The relapse is processed so it can become a learning experience for the client.

8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation

The CMRPT views resistance on a continuum from simple denial of chemical addiction to delusion states based on cognitive impairments or severe personality pathology. The underlying cause of the denial is assessed, and special treatment interventions are set up to deal with it.

Since clients in severe and rigid denial are inappropriate candidates for RP therapy, they are referred to transitional counseling programs that are designed to deal with individuals who have high levels of denial and treatment resistance. When clients become treatment ready, they can reapply for admission to the RP program.

8.6 Strategies for Dealing With Crises

Crisis situations are viewed as critical relapse warning signs. The implementation of the standard treatment plan is discontinued, and special crisis management procedures are implemented to stabilize the crisis. Once the crisis is stabilized, the client is reassessed, the treatment plan is updated, and the client returns to working on standard RP tasks as outlined in the treatment plan.

If possible, the crisis is stabilized in the context of the CMRPT. If the crisis is so severe that it interferes with the client's ability to be involved, the client is transferred to another type or level of care to focus on the crisis stabilization.

9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT

The CMRPT has a family treatment component that involves communication and intervention training around the developing warning signs, relapse, and early intervention, which allow the client and family members to have a concrete behavioral response should alcohol or other drug use recur.

Family therapy is normally delivered in a "parallel model." The client is involved in individual and group therapy for recovery from chemical addiction, and family members (especially the spouse or intimate partner) are encouraged to enter individual and group therapy for the treatment of coaddiction and other personal issues. Sessions are established to work with specific couples and family communication training and problem solving. Special emphasis is placed on developing open communication around recovery goals, relapse warning signs for both chemical addiction and coaddiction, family warning sign identification and management skills, and family intervention planning in the event that alcohol or other drug use or acting out codependent behavior occur.

The goal of family therapy is to remove the chemically dependent partner from the identified client role and create a family recovery focus in which each family member initiates a personal recovery program for chemical addiction or coaddiction. The family then needs to establish a family recovery plan for improving the overall functioning of the family system.

Family therapy is viewed as important but adjunctive to RP therapy. Many relapse-prone clients do not have a committed family system, and many family members refuse to become involved in therapy because of the long history of past failure. Many relapse-prone clients can and do achieve long-term recovery with the CMRPT even though the family is not involved in treatment.

REFERENCES

George, W.H. Marlatt and Gordon's Relapse Prevention Model: A cognitive-behavioral approach to understanding and preventing relapse. J Chem Depend Treat 2(2):153-169, 1989.

Gorski, T. The Staying Sober Workbook: A Serious Solution for the Problem of Relapse. Independence, MO: Herald House/ Independence Press, 1988.

Gorski, T. How to Start Relapse Prevention Support Groups. Independence, MO: Herald House/Independence Press, 1989b.

Gorski, T., and Miller, M. Staying Sober: A Guide for Relapse Prevention. Independence, MO: Herald House/Independence Press, 1986.

Gorski, T.T. The CENAPS® Model of Relapse Prevention Planning. In: Daly, D.W. Relapse: Conceptual, Research, and Clinical Perspectives. Hayworth Press, 1989a. pp. 153-161 and J Chem Depend Treat (2)2, 1989a.

Marlatt, G.A., and Gordon, J.R., eds. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985. pp. 351-416.

Trotter, C. Double Bind: Recovery and Relapse Prevention for the Chemically Dependent Sexual Abuse Survivor. Independence, MO: Herald House/Independence Press, 1992.

AUTHOR

Terence T. Gorski
President
The CENAPS® Corporation
18650 Dixie Highway
Homewood, IL 60430

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