Love and Control

November 15, 2014

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When you love someone you have no control. Love is born in giving up control to another who may hurt you in your vulnerability. Love dies when control is taken back to end the pain. Love is always a strange mix of ecstasy and agony and survives in the ability to tolerate both.

Getting Love Right

GORSKI BOOKS


The Fall of the Berlin Law

November 9, 2014

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By Terence T. Gorski,
Author

Today is 25th Anniversary of the Fall of the Berlin Wall (November 9, 2014).
Twenty-five years ago today the Berlin Wall was torn downsizing the beginning of the end of the would alliance of Communism institutionalized by the soviet unit.

Taking down the wall was a peaceful process because Communism had run its murderous course. The failure of communism showed that governments are condemned to fail if they are based upon:
1. Imposing a rigid and inflexible ideology enforced by violence that denies the freedom of thought, speech, and equal opportunity to seek happiness;
2. Centralizing economic and industrial control under government; and
3. Using military strength and conquest as its primary or only source of standing in the world.

People require the freedom of thought, speech, opportunity, and the right to own property as a necessary condition of their very humanity.

For more information: http://www.history.com/topics/cold-war/berlin-wall

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Live Sober- Be Responsible – Live Free


Relapse Prevention Therapy (RPT) – An Affordable Evidence-based Practice

November 8, 2014

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By Terence T. Gorski, Author

 

Relapse Prevention Therapy (RPT) is an Evidence-based practiced that is recognized by both the National Registry of Evidence-based Programs and Practices (NREPP) and the National Institute of Drug Abuse. This is important because relapse following drug treatment is quite common and a collection of tools have been forged into a system for both preventing relapse and stopping it quickly should it occur. “RPT is a behavioral self-control program that teaches individuals how to anticipate and cope with the potential for relapse” (NREPP). In addition, RPT serves to normalize relapse as part of the overall recovery process, thus reducing the negative feelings and behaviors that result from a setback. RPT also provided relapse tools and techniques that patients learn early in treatment that can stop relapse quickly should it occur.

The GORSKI-CENAPS Model of RPT brings proven evidence-based practices to recovery and relapse prevention by providing effective and easy to use methods for identifying and managing early relapse warning signs and high risk situations. It also presents methods for planning to stop relapse quickly should it occur. All of the key practices of evidenced-based Relapse Prevention Therapy (RPT) are made available in practical and easy to use workbooks. Training is available to teach the most effective ways to make use the workbooks in individual and group therapy and in support groups. There is also an internationally registry of Certified Relapse Prevention Specialists (CRPS) that are trained to support RPT program implementation.

The Research Supporting RPT Effectiveness

Prevention (RP) is an evidence-based intervention. There is compelling evidence in the literature documenting its effectiveness.

First, let’s look at the results of a meta-analysis of 26 published and unpublished studies with 70 hypothesis tests representing a sample of 9,504 participants. (Irvin et al, 1999)

  • Relapse Prevention (RP) was found to be a widely adopted cognitive-behavioral treatment (CBT) for alcohol, smoking, and other substance use.
  • RP was generally effective, particularly for alcohol problems.
  • RP was most effective with alcohol or polysubstance use disorders combined with the adjunctive use of medication

Validation of Gorski’s Relapse Warning Signs

Though it has enjoyed widespread popularity, Gorski’s post-acute withdrawal syndrome (PAWS) model of relapse has been subjected to little scientific scrutiny. A scale to operationalize Gorski’s 37 warning signs was developed and tested in a larger prospective study of predictors of relapse. Of central interest were: (1) whether the warning signs hypothesized by Gorski are interrelated in a meaningful single factor and (2) whether the hypothesized syndrome would accurately predict subsequent relapses.

A sample of 122 individuals (84 men) entering treatment for alcohol problems was followed at 2-month intervals for 1 year. The Assessment of Warning-signs of Relapse (AWARE) scale was administered at each assessment point, and the occurrence of both slips (any drinking) and relapses (heavy drinking) was monitored during each subsequent 2-month interval. Principal factor analysis was used to study the factor structure of the warning signs.

The results showed that: (1) Of the 37 warning signs, 28 clustered as a robust single factor with excellent internal consistency (Cronbach’s alpha: 0.92-0.93); (2) A conservative evaluation of test-retest stability across 2-month intervals estimated reliability at r = 0.80. (3) After covarying for prior drinking status, clients’ AWARE scores significantly predicted subsequent slips and relapses. Relapse rates for clients with highest AWARE scores, as projected by regression equations, were 33 to 46 percentage points higher than those for clients with lowest AWARE scores, after taking into account prior drinking status.

The conclusion is that this scale of Gorski’s warning signs appears to be a reliable and valid predictor of alcohol relapses. (J. Stud. Alcohol 61: 759-765, 2000)

Relapse Prevention (RP): Controlled Clinical Trials (Carroll 1996)

(1) More than 24 randomized controlled trials have evaluated the effectiveness of cognitive-behavioral relapse prevention treatment on substance use outcomes among adult smokers, alcohol, cocaine, marijuana, and other types of substance abusers. Review of this body of literature suggests that, across substances of abuse but most strongly for smoking cessation,

(2) There is evidence for the effectiveness of relapse prevention compared with no-treatment controls across all drug categories.

(3) Relapse Prevention is most effective at:

  • Treating patients with long histories of chronic relapse after attempting recovery with other treatment methods.
  • Maintaining the positive effects of improvements made during treatment (enhanced durability of effects)
  • Reducing the length and severity of damage caused by relapse episodes when they occur;

(4)      The positive effects of RP are enhanced by patient-treatment matching.

(5) Patient-treatment matching improves outcomes for patients at higher levels of impairment along dimensions such as psychopathology or dependence severity.

Manualized Treatment

Manualized Treatment Improves Effectiveness of treatment (i.e. increases recovery rates, decreases relapse rates, and produces shorter less destructive relapse episodes. The results are achieved while reducing time in therapy.

The primary treatment manuals that help produce these outcomes are:

  1. Starting Recovery With Relapse Prevention Workbook: A workbook designed to integrate basic relapse prevention principles in to the first attempts at addiction recovery.
  2. Cognitive Restructuring for Addiction Workbook: A workbook designed to teach and apply the basic recovery skills of thought management, feeling management, behavior management, impulse control, the use of mental imagery, and a serious of relaxation methods, including mindfulness meditation, that has been proven to enhance the effectiveness of the cognitive component of relapse prevention. This work allows an easy application of RPT methods to a wide variety of additive and mental health problems.
  3. Relapse Prevention Counseling (RPC) Workbook: This is a guide for understanding and managing craving and high risk situations to avoid relapse during the critical first ninety days of recovery.
  4. Relapse Prevention Therapy (RPT) Workbook: This is a guide for helping recovering people with a stable recovery program to identify and manage the personality and lifestyle problems that can so must pain and dysfunction in recovery that self-medication seems like a positive choice. This workbook takes RPT to a deep psychotherapy level.
  5. Problem Solving Group Therapy (PSGT): There are two simple guidelines for using RPT in problem solving groups. There is a Participant Guide to prepare group members with easy to understand information on how to succeed at group therapy and a group leader guide giving in-depth instruction how to start, conduct, and manage common problems that occur in problem solving groups.

When these five practical tools are brought together into a well designed and comprehensive treatment program the quality of care, moral of the staff, and positive long-term outcomes of treatment tend to improve.

WORKBOOKS  USING RELAPSE PREVENTION THERAPY (RPT) – AN EVIDENCE-BASED PRACTICE  http://wp.me/p11fHz-7s

References

The CENAPS Model of Relapse Prevention was originally developed by Terence T. Gorski and continually updated to integrate new research findings. (Gorski 1990, )

Carroll, Kathleen M., Relapse prevention as a psychosocial treatment: A review of controlled clinical trials. Experimental and Clinical Psychopharmacology, Vol 4(1), Feb 1996, 46-54.

Gorski, Terence T., The CENAPS Model of Relapse Prevention: Basic Principles and Procedures, Journal of Psychoactive Drugs, Vol. 22, Issue 2, 1990, pages 125- 133, ON THE INTERNET: http://www.tandfonline.com/doi/abs/10.1080/02791072.1990.10472538

Irvin, Jennifer E.; Bowers, Clint A.; Dunn, Michael E.; Wang, Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology, Vol 67(4), Aug 1999, 563-570.

Miller, William R. and Harris, Richard J.  A Simple Scale of Gorski’s Warning Signs for Relapse, Journal of Studies on Alcohol and Drugs, Volume 61, 2000, Issue 5: September 2000 ON THE INTERNET: http://www.jsad.com/jsad/article/A_Simple_Scale_of_Gorskis_Warning_Signs_for_Relapse/814.html

 

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California Becomes the First State to Defelonize Drug Use

November 7, 2014

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November 5, 2014
by Johnny Magdaleno

Introduction by Terence T. Gorski
An army of concerned citizens, including myself, has advocated against excessive prison sentences for non-violent drug offenders and reinvesting the money spent on incarceration to community-based addiction treatment and solid approaches for developing sober communities.

California, previously a leader in incarcerating nonviolent drug addicts, has reversed direction in the passage of proposition 47. Hopefully, as a result of the recent election, a trend in changing from a War on Drugs Policy to a Public Health Addiction Policy that includes a strong emphasis on developing sober communities based upon the attraction to re benefits of recovery rather than the fear of punishment.

I believe that this type of legislation that is based upon the principles of decriminalization and reclassification of nonviolent drug possession and personal use can be a good thing.
The folloI believe that the fact. Here’s why:

1. Sentences for nonviolent drug offenders are draconian and have introduced racial bias due to how how and where drug laws are enforced.

2. The War on Drugs Policy has been an expensive failure in terms of managing the national epidemic of drug addiction.

3. Provisions in the legislation will redirect the funding saved by reducing the prison population to community reentry programs, expansion of community-based treatment resources, and the building sober communities based upon the attraction of living among sober and responsible rather than the threat of incarceration.

4. Many children now orphaned because of parental incarceration can be reunited with their families instead of being warehouses in child welfare systems.
This can be a tremendous contribution to a better future if the process of family unification is supported by effective family therapy, drug prevention and treatment, and special services for adolescents.

5. Police and court resources can be redirected to their true mission, stopping violent crime and protecting our communities from violent criminals.

More detailed information is available: http://fivethirtyeight.com/datalab/what-to-expect-california-prop-47/

This defelonization of drug use alone is only one part of the managing the problem. Addiction professionals, including Social Workers, Psychologist’s, and Counsels will need to stand up with other community leaders to develop policies and programs that support and encourage sobriety and responsibility, strongly discourage alcohol and drug abuse, and make concerted efforts to de-glamorize drinking and drug use. A planned program for holding up as heroes and role models the sober and responsible people who make positive contributions to their communities.
xplores this topic in depth
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Gorski Books On Criminal Justice and Addiction

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Spirituality – One Point of View

November 5, 2014

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By Terence T. Gorski,
Author

I think of spirituality as the nonphysical aspects of the human being that involve:

– Thinking,
– Feeling,
– Imagining,
– Learning, and
– Remembering,

These nonphysical aspects give us:
– The ability to establish conscious contact with a power greater than ourselves.
– The capacity for self-awareness,
– The ability to make decisions and exercise free will,
– The ability to seek and find a sense of meaning and purpose in life,
– The the ability to embrace, endure, transcend, and find meaning in the pain, problems, and suffering in life
– The capacity to enjoy and find peace in a wide variety of human experience.

With the continuing evolution of thought, there is a large area of overlapping concepts that can be described in both spiritual and psychological language while expressing essentially the same ideas and concepts. The future challenge will be to agree upon a common language to reduce confusion and misunderstanding and facilitate the continued growth of the human mind and spirit that is aligned with higher principles reflecting goodness love, and peace among of of mankind.

The above statement summarizes my best thinking on spirituality at this moment. Please remember that I am but a fallible human being who could be wrong.

Terence T. Gorski
November 4, 2014


The Biopsychosocial Revolution

November 5, 2014

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J Gen Intern Med. Apr 2002; 17(4): 309–310.
doi: 10.1046/j.1525-1497.2002.20210.x
PMCID: PMC1495036

Introduction by Terence T. Gorski

The biopsychosocial model has been an integral part of The Gorski-CENAPS Model of recovery and relapse prevention since the late 1970’s. The recognition of this approach has proven effective and is expanding to many areas of medicine. The following article gives some interesting information.
Terence T. Gorski

Interviewing and Provider-patient Relationships are Becoming Key Issues for Primary Care
ROBERT C SMITH, MD, ScM1
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495036/?report=classic
1. George Engel proposed in 1961 that the biopsychosocial Model (BPSM) should become a landmark for understanding medicine as a science.1,2*

2. The BPSM prompted a revolution in medical thinking by providing a compelling rational and frame if reference for integrating the physical, psychological, social and spiritual aspects of human beings.

3. Following the revolution in physics at the turn of the last century, science gradually moved away from previous linear, cause–effect thinking.

4. To that point, understandably, medicine’s guiding biomedical model focused only on diseases.

5. Beginning with Engel’s (BPSM) model, medical thinking slowly evolved by incorporating and integrating psychosocial components into the practice of medicine.

6. The biopsychosocial model stems from what many consider the modern articulation of science, general system theory.3–5

7. Engel’s model prescribes a fundamentally different path from the still-guiding biomedical model: to be scientific, according to Engel a model for medicine must include:

(1) The biological dimensions of both health and disease of all body systems;

(2) The psychological dimensions (thinking, feeling, imagining, and higher levels is self awareness and altered consciousness);

(3) The social dimensions (interpersonal, emotional, family, and larger communit)y.

8. By integrating these multiple, interacting components of the patient as an integrated whole, the subject of medical science changes from specific organs and body system to the entire human being.

9. By seriously considering all physical and nonphysical aspects of all people studied by science we become more humanistic. We link science and humanism — critical thinking with emotionality.

10. While this revolution/evolution in medicine has not yet replaced the biomedical model, the biopsychosocial model now is taught in most medical schools, and most practitioners are familiar with the term and its meaning.6

11. The problem we now face is that the model itself does not address the intricate process needed for achieving relevant biopsychosocial understanding of the patient.

12. Identified by the Western Ontario group, “patient-centered” medicine developed as the approach (process) for implementing or operationalizing the biopsychosocial model.7–10

13. This new approach puts the patient’s needs foremost (e.g., interests, concerns, questions, ideas, requests) but continues to include disease issues.

14. When applied to clinical interviewing, we always integrate the patient-centered process with ‘doctor-centered’ interviewing for disease details.

15. By enhancing communication and provider-patient relationships (PPRs), patient-centered interviewing produces the relevant biopsychosocial reality of each patient at each visit.

16. It changes the model from an intellectual construct to a practical means for a more scientific understanding of every patient.

17. Patient-centered interviewing is the flip side of the biopsychosocial coin; they go hand-in-hand, process and content.

18. Encompassing the dyadic patient-centered approach, newly described “relationship-centered” care (RCC) goes one step further.11,12

19. RCC extends the person-centered process to the remainder of the medical system, encouraging communication and relational principles at all levels, e.g., among administrators, nurses, doctors, and unions.13

20. The Journal of General Internal Medicine highlights the PPR and communication (and, therefore, the biopsychosocial model) in primary care research.

21. For example, the work of Forrest et al. concerns the better understanding of some determinants of the PPR.14

22. They found that HMO patients rated the PPR lower when required to select a physician from a list and/or to get authorization for referral.

23. The authors avoided the common pitfall of criticizing managed care and urging a change in its rules. Rather, while the HMO is doing its job to control continuously escalating costs,15 the authors acknowledge that the focus could profitably be upon the PPR itself (and, inextricably related, communication).

24. This laudable position recognizes that the exigencies of managed care have increased already strong demands upon physicians to establish effective relationships and communication.

25. The wisdom of focusing upon the PPR and not recommending simple administrative change can be found in a literature replete with the health outcome benefits of being patient-centered, many of which studies were randomized controlled trials; see reviews.16–18

26. The authors caution rightly that study other than their cross-sectional work will be needed to place their findings in proper perspective. For example, we do not know if administrative changes will have any impact on health without simultaneously addressing communication/PPR.

27. Heisler et al. did not directly study the PPR but evaluated closely related communication-based predictors:
– patients’ perceptions of participatory decision making,
– informing patients, and understanding.19

29. They found that self-reported, improved outcomes of diabetes self-management were closely related to informing patients and, not surprisingly, to patient understanding.

29. Informing and motivating patients are key patient-centered interviewing skills.

30. But understanding alone is not sufficient, particularly where the patient may need to make unwanted changes, such as to begin a diet or quit smoking.

31. For example, the following additional factors, among others, can also affect outcomes: specific PPR variables (e.g., empathy, open-ended inquiry), self-efficacy, satisfaction, compliance, cognitive ability, stress level, autonomy, and readiness to change.

32. While the authors’ caveats about a cross-sectional study are germane, we applaud their addition to the increasing body of research indicating that patients benefit from being informed.

33. We may think we provide sufficient information, but patients typically disagree 20–22 and, perhaps with the stress of their illnesses, they often forget information they do receive.23

34. These papers, and several others in this issue, underscore the central role of communication and PPR in primary care and, therefore, the need to train students and physicians in patient-centered interviewing methods.

35. While it is encouraging that more training now occurs, we need much more teaching for both students6 and residents.24

36. Although we have effective patient-centered interviewing methods, the need to teach them remains, especially for those beyond residency training, who often have had little previous exposure.

37. For continuing medical education and faculty development, a wonderful resource has evolved (nurtured by the Society of General Internal Medicine) over the last 2 decades and has been a unique, valuable dissemination mechanism: The American Academy on Physician and Patient (AAPP) (www.physicianpatient.org ). AAPP provides week-long training at its annual meeting (June) and also frequently conducts 1- to 2-day training sessions throughout the United States, always tailored to the needs and interests of those who invite them.

38. The amount as well as the quality of research about PPR/communication can encourage us. These works provide testimony to our increasing focus upon the psychosocial aspects of primary care and to moving beyond an isolated interest in disease.

39. Continuing to painstakingly generate sound evidence for “psychosocial medicine” fosters a needed maturation of this newer aspect of medicine—a prerequisite for the blossoming of a more scientific medicine.

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Footnotes
*Of historical note, in a letter to the editor in 1961, Engel first used the term “bio-psycho-social-cultural.”25

For simplicity, the name was shortened. Engel viewed the social domain of the model as encompassing cultural, spiritual, and other broader issues (personal communication).

Go to:
REFERENCES
1. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535–44. [PubMed]
2. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129–36. [PubMed]
3. von Bertalanffy L. General System Theory: Foundations, Development, Application. Revised Ed. New York, NY: George Braziller; 1968.
4. Weiss PA. The Science of Life: The Living System–A System for Living. Mount Kisco, NY: Futura Publishing Co.; 1973.
5. Brody H. The systems view of man: implications for medicine, science, and ethics. Perspect Biol Med. 1973;17:71–92. [PubMed]
6. Novack DH, Volk G, Drossman DA, Lipkin M., Jr Medical interviewing and interpersonal skills teaching in US medical schools. JAMA. 1993;269:2101–5. [PubMed]
7. Levenstein JH, McCracken EC, McWhinney IR, Stewart MA, Brown JB. The patient-centered clinical method. 1. A model for the doctor-patient interaction in family medicine. J Fam Pract. 1986;3:24–30. [PubMed]
8. McWhinney I. The need for a transformed clinical method. In: Stewart M, Roter D, editors. Communicating with Medical Patients. London: Sage Publications; 1989. pp. 25–42.
9. Levenstein JH, Brown JB, Weston WW, Stewart M, McCracken EC, McWhinney I. Patient-centered clinical interviewing. In: Stewart M, Roter D, editors. Communicating with Medical Patients. London: Sage Publications; 1989. pp. 107–20.
10. McWhinney I. An Introduction to Family Medicine. New York: Oxford University Press; 1981.
11. Inui TS. What are the sciences of relationship-centered primary care. J Fam Pract. 1996;42:171–7. [PubMed]
12. Tresolini CP. Pew-Fetzer Task Force: Health Professions Education and Relationship-Centered Care. San Francisco: Pew Health Professions Commission; 1994.
13. Suchman AL, Botelho RJ, Hinton-Walker P, editors. Partnerships in Healthcare: Transforming Relational Process. Rochester, NY: University of Rochester Press; 1998.
14. Forrest CB, Shi L, vonSchrader S, Ng J. Managed care, primary care, and the patient-practitioner relationship. J Gen Intern Med. 2002;17:270–7. [PMC free article] [PubMed]
15. Pear R. Propelled by drug and hospital costs, health spending surged in 2000. New York Times; p. A14. January 8, 2002.
16. Williams GC, Frankel RM, Campbell TL, Deci EL. Research on relationship-centered care and healthcare outcomes from the Rochester Biopsychosocial Program: a self-determination theory integration. Families, Systems and Health. 2000;18:79–90.
17. Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J. 1995;152:1423–33. [PMC free article] [PubMed]
18. Williams S, Weinman J, Dale J. Doctor-patient communication and patient satisfaction: a review. Fam Pract Res J. 1998;15:480–92. [PubMed]
19. Heisler M, Bouknight RB, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision-making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17:243–52. [PMC free article] [PubMed]
20. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients’ understanding of the postdischarge treatment plan. J Gen Intern Med. 1997;157:1026–30. [PubMed]
21. Waitzkin H. Doctor-patient communication: clinical implications of social scientific research. JAMA. 1984;252:2441–6. [PubMed]
22. Waitzkin H. Information giving in medical care. J Health Soc Behav. 1985;26:81–101. [PubMed]
23. Ley P. Doctor-patient communication: some quantitative estimates of the role of cognitive factors in non-compliance. J Hypertens. 1985;3:51–5. [PubMed]
24. Merkel WT, Margolis RB, Smith RC. Teaching humanistic and psychosocial aspects of care: current practices and attitudes. J Gen Intern Med. 1990;5:34–41. [PubMed]
25. Engel GL, editor. To the editor. Psychosom Med. 1961;23:426–9.
Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine


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