Relapse Prevention Therapy (RPT): An Evidence-based Practice

December 31, 2013

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Relapse following drug treatment is quite common. “Relapse Prevention Therapy 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.

The GORSKI-CENAPS Model brings proven evidence-based practices to recovery and relapse prevention by providing proven 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.

National Registry of Evidence-based Practices (NREPP)
North Carolina Practice Improvement Collaborative (NCPIC)

WORKBOOKS  USING RELAPSE PREVENTION THERAPY (RPT) – AN EVIDENCE-BASED PRACTICE


Relapse: A Monster In The Recovery Machine

November 23, 2013

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By Terence T. Gorski
In sobriety, relapse can sneak up behind us like a phantom in the dark.
There are many warning signs that can lead to relapse. No one thing brings us into recovery and no one thing leads us back into addiction. Recovery is the process of making and then remaking the decision not only to STOP drinking and drugging – but also to start and then maintain a way of life that provides meaning and purpose to us in sobriety. We also need ongoing support for recovery and a willingness to learn new ways of thinking and being. Solutions? Yes! Simple solutions? Don’t I wish!

Relapse is a process that begins long before the first use of alcohol or other drugs. Like an avalanche, the first signs are small and seem insignificant. If ignored the problems leading to relapse keep crashing down hill and growing in strength.

Being alert for the subtle warning signs that lead to relapse is, in my opinion, a critical recovery skill. These relapse warning signs start, not with thoughts or urges to use alcohol or other drugs, but with simple problems and subtle ways of irrational thinking that cause unnecessary pain and problems in recovery. When the pain is severe and the problems overwhelming, addiction sneaks up behind us like a phantom in the dark. The addiction whispers in our ear. It tells us over and over again that the only thing that can stop the pain and solve our problems is using our drug of choice. Then, and only then, comes the addictive thinking and the craving. At that moment, before putting our drug of choice in our bodies, we are in a crisis of sobriety. We are standing hypnotized by the approaching avalanche of addiction. If we don’t awake from the trance in time, we will be crushed.

Simplistic answers to the problem of relapse, in my experience, are comforting but not helpful. We must do the work of learning what this “cunning, baffling, and powerful” disease is doing to us in our sobriety. Once we are sure we have it beat forever, the disease has already won! It is only a matter of time. This is why in my understanding of the 12-Steps, we must work a daily program of rigorous honesty and correct problems as soon as we are aware of them. This early identification and solution of problems is a critical survival skill for those of us who are addicted.

Gorski Books:
Gorski Home Studies: www.cenaps.com


Addiction Treatment and the Affordable Care Act (ACA)

November 22, 2013

By Celia Vimont
February 26, 2013

An Introduction
By Terence T. Gorski

The following article by By Celia Vimont summarizes the predictions made by Thomas McLellan, PhD, who reported at the 2013 annual meeting of the New York Society of Addiction Medicine that he believes that the Affordable Care Act (ACA) will revolutionize the field of substance abuse treatment.

I am not as optimistic as as Dr. McLellan about the positive impacts of the ACA on overall recovery rates for addiction clients. Here’s why;

1. When addiction services are merged into medical services the addiction tends not be diagnosed and initial referrals are made to individual doctors most who use medication management.

2. Residential Rehabilitation will not be considered an essential services.

3. Brief screening and early intervention will be attempted but relapse rates tend to be high.

4. Stigma and poly-drug abuse that mixes legal and illegal drugs will both deter early voluntary intervention.

Here is the article reporting on Dr. McLellan’s projections, which are far more optimistic than mine.
—–
The ACA Could Provide Substance Abuse Treatment to Millions of New Patients”

“It will have more far-reaching positive consequences for substance abuse treatment than anything in my lifetime, including the discovery of methadone,” he said at the recent annual meeting of the New York Society of Addiction Medicine.

“It will integrate substance abuse treatment into the rest of health care.”

Currently, just 2.3 million Americans receive any type of substance abuse treatment, which is less than one percent of the total population of people who are affected by the most serious of the substance use disorders—addiction, said Dr. McLellan, who is a former Deputy Director of the White House Office of National Drug Control Policy.

Most who receive treatment are severely affected, he said.
“If diabetes were treated like substance abuse, only people in the most advanced stages of illness would be covered, such as those who had already lost their vision or had severe kidney damage,” he said.

A. Thomas McLellan, PhD
Dr. McLellan reported that 23 million American adults suffer from substance abuse or dependence—about the same number of adults who have diabetes.

An additional 60 million people engage in “medically harmful” substance use, such as a woman whose two daily glasses of wine fuels growth of her breast cancer. The new law will allow millions more people to receive treatment, including those whose substance abuse is just emerging.

Under the ACA, substance abuse treatment will also become part of primary care, and will be focused more on prevention.

Substance abuse treatment will also be considered an “essential service,” meaning health plans are required to provide it. They must treat the full spectrum of the disorder, including people who are in the early stages of substance abuse. “There will be more prevention, early intervention and treatment options,” he said. “The result will be better, and less expensive, outcomes.”

By the end of 2014, under the ACA, coverage of substance use disorders is likely to be comparable to that of other chronic illnesses, such as hypertension, asthma and diabetes. Government insurers (Medicare and Medicaid) will cover physician visits (including screening, brief intervention, assessment, evaluation and medication), clinic visits, home health visits, family counseling, alcohol and drug testing, four maintenance and anti-craving medications, monitoring tests and smoking cessation.

Currently, federal benefits, such as Medicaid and Medicare, focus on inpatient services, like detox programs, but do not cover office visits for substance abuse treatments. In contrast, Medicaid covers 100 percent of diabetes-related physician visits, clinic visits and home health visits, as well as glucose tests, monitors and supplies, insulin and four other diabetes medications, foot and eye exams, and smoking cessation for diabetics.

“These are all primary care prevention and management services, which are the most effective and cheapest way of managing illness,” he said.

The impact of these new rules will be quite substantial, since an estimated 65 percent of insured Americans are covered by Medicaid or Medicare, and the rest are covered by insurance companies that base their benefits structure on federal benefits, said Dr. McLellan.

As addiction becomes treated as a chronic illness, pharmaceutical companies will be much more interested in developing new medications, he added.

“Immense markets are being created,” he said. “Until now, there have been about 13,000 treatment providers for substance use disorders, and less than half of those are doctors. Now, 550,000 primary care doctors, in addition to nurses who can prescribe medications, will be caring for these patients.”

ON THE INTERNET: http://www.drugfree.org/join-together/addiction/affordable-care-act-to-provide-substance-abuse-treatment-to-millions-of-new-patients

GORSKI BOOKS
CENAPS OFFICES OFFICES: http://www.cenaps.com


Recovery: SAMHSA’s Working Definition

October 15, 2013

SAMHSA’s Working Definition of Recovery  encompasses both mental disorders and/or substance use disorders. This will be a foundational definition for recovery as defined by the Affordable Health Care Act.

You can compare this with GORSKI’S WORKING DEFINITION OF RECOVERY

The Substance Abuse and Mental Health Services (SAMHSA)recognizes there are many different pathways to recovery and each individual determines his or her own way. SAMHSA engaged in a dialogue with consumers,persons in recovery, family members, advocates, policy-makers, administrators,providers, and others to develop the following definition and   for recovery.  The urgency of health reform compels SAMHSA to define recovery and to promote the availability, quality, and financing   services and supports that facilitate recovery for individuals.  In addition, the integration mandate in title II of the Americans with Disabilities Act and the Supreme Court’s decision in Olmstead v. L.C., 527 U.S.581 (1999) provide legal requirements that are consistent with SAMHSA’s mission to promote a high-quality and satisfying life in the community for  all Americans.

Recovery from Mental Disorders and/or Substance Use Disorders:  A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major dimensions that support a life in recovery:

•      Health:  overcoming or managing one’sdisease(s) or symptoms—for example, abstaining from use of alcohol,  , and non-prescribed medications if one has an addiction problem—and foreveryone in recovery, making informed, healthy choices that support physical and emotional wellbeing.

•      Home:  a stable and safe place to live;

•      Purpose: meaningful daily activities, such as a job, school, volunteerism,  family care taking, or creative endeavors, and the independence, income and resources to participate in society; and

•      Community: relationships and social networks that provide support, friendship, love,and hope.

 Guiding Principles of Recovery

Recovery emerges from hope:  The belief that recovery is real provides the essential and motivating message of a better future – that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them.  Hope is internalized and can be fostered by peers, families, providers, allies, and others.  Hope is the catalyst of the recovery process.

Recovery is person-driven:  Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s) towards those goals. Individuals optimize their autonomy and independence to the greatest extent possible by leading, controlling, and exercising choice over the services and supports that assist their recovery and resilience. In so doing, they are empowered and provided the resources to make informed decisions, initiate recovery, build on their strengths, and gain or regain control over their lives. 

Recovery occurs via many pathways:  Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds including trauma experiences that affect and determine their pathway(s) to recovery. Recovery is built on the multiple capacities,strengths, talents, coping abilities, resources, and inherent value of each individual.  Recovery pathways are highly personalized.  They may include professional clinical treatment; use of medications; support from families and in schools; faith-based approaches; peer support; and other approaches.  Recovery is non-linear, characterized by continual growth and improved functioning that may involve setbacks.  Because setbacks are a natural, though not inevitable, part of the recovery process, it is essential to foster resilience for all individuals and families. Abstinence from the use of alcohol, illicit drugs, and non-prescribed medications is the goal for those with addictions.  Use of tobacco and non-prescribed or illicit drugs is not safe for anyone. In some cases, recovery pathways can be enabled by creating a supportive environment. This is especially true for children, who may not have the legal or developmental capacity to set their own course.

 Recovery is holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit,and community.  This includes addressing: self-care practices, family, housing, employment, education, clinical treatment for mental disorders and substance use disorders, services and supports, primary healthcare, dental care,complementary and alternative services, faith, spirituality, creativity, social networks, transportation, and community participation.  The array of services and supports available should be integrated and coordinated.

Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Peers encourage and engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles, and community. Through helping others and giving back to the community, one helpsone’s self.  Peer-operated supports and services provide important resources to assist people along their journeys of recovery and wellness. Professionals can also play an important role in the recovery process by providing clinical treatment and other services that support individuals in their chosen recovery paths.  While peers and allies play an important role for many in recovery,their role for children and youth may be slightly different.  Peer supports for families are very important for children with behavioral health problems and can also play a supportive role for youth in recovery.

Recovery is supported through relationship and social networks: An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change.  Family members, peers, providers,faith groups, community members, and other allies form vital support networks.Through these relationships, people leave unhealthy and/or unfulfilling life roles behind and engage in new roles (e.g., partner, caregiver, friend,student, employee) that lead to a greater sense of belonging, personhood,empowerment, autonomy, social inclusion, and community participation. 

Recovery is culturally based and influenced: Culture and cultural background in all of its diverse representations including values,traditions, and beliefs are keys in determining a person’s journey and unique pathway to recovery. Services should be culturally grounded, attuned,sensitive, congruent, and competent, as well as personalized to meet each individual’sunique needs.

Recovery is supported by addressing trauma:  The experience of trauma (such as physical or sexual abuse, domestic violence, war,disaster, and others) is often a precursor to or associated with alcohol and drug use, mental health problems, and related issues.  Services and supports should be trauma-informed to foster safety (physical and emotional)and trust, as well as promote choice, empowerment, and collaboration.

Recovery involves individual, family, and community strengths and responsibility:  Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery. Individuals should be supported in speaking for themselves. Families and significant others have responsibilities to support their loved ones, especially for children and youth in recovery. Communities have responsibilities to provide opportunities and resources to address discrimination and to foster social inclusion and recovery.  Individuals in recovery also have a social responsibility and should have the ability to join with peers to speak collectively about their strengths, needs, wants, desires, and aspirations.

Recovery is based on respect: Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems – including protecting their rights and eliminating discrimination – are crucial in achieving recovery.  There is a need to acknowledge that taking steps towards recovery may require great courage. Self-acceptance, developing a positive and meaningful sense of identity, and regaining belief in one’s self are particularly important.

SAMHSA has developed this working definition of recovery to help policy makers, providers, funders, peers/consumers, and others design,measure, and reimburse for integrated and holistic services and supports to more effectively meet the individualized needs of those served.

Many advances have been made to promote recovery concepts and practices.  There are a variety of effective models and practices that States, communities, providers, and others can use to promote recovery. However, much work remains to ensure that recovery-oriented behavioral health services and systems are adopted and implemented in every state and community.  Drawing on research, practice, and personal experience of recovering individuals, within the context of health reform, SAMHSA will lead efforts to advance the understanding of recovery and ensure that vital recovery supports and services are available and accessible to all who need and want them.

A CRITICAL REVIEW OF THE SAMHSA DEFINITION OF RECOVERY

The big problem with the SAMHSA definition of recovery is that it does not specifically answer the question “recovery from what?” By including chemical and behavioral addictions and then expanding the universe to all mental disorders, it misses the mark.

I believe the research clearly shows that there are non-addictied substance abusers who have episodes of abuse related to stage of life and life circumstances. A key defining idea of the DSM-III and IV criteria is that there are substance dependence disorders, generally called addiction, that are marked by a pattern of compulsive use, the description of matches the idea of progressive loss of control discussed, is consistent with early research which has be reexamined over more the forty years and found to be powerful descriptions.

The treatment of recovery from non-addictive substance abuse is different, in many ways from the treatment o substance dependence (addiction). Substance dependence (addiction) with carries with it an underlying impairment of the reward centers of the brain that do not rapidly return to normal and produce long-term cognitive impairment often described as Post Acute Withdrawal (PAW) or Protracted Withdrawal. PAW is stress sensitive (i.e. stress increases the degree of impairment in cognitive functioning) and as a result is highly correlated with stress-induced relapse models.

We must deal with this critical question: What exactly is the disease or disorder we are dealing with? How severe? What stage of severity? What past treatment? What coexisting mental or physical disorders?
The over-generalization of a recovery process from everything, implies that addiction, abuse, and mental disorders are essentially the same thing. There is compelling evidence that this is not the case. There are critical differences between disorders which dictate disorder specific treatment and differences in the recovery process.

I had hoped we gotten past the “addiction is anything you want it to be phase” in the development of the addiction treatment profession. Apparently I was wrong.

In my opinion the SAMHSA operational definition of recovery and the DSM 5 reformulation of criteria for addictive disorders is a step back into vague generalities that maintain tired old disagreements that have been settled in the literature.

A precise definition of the disorder being treated and specific principles and practices that professionals and recovering people can use as they progress in recovery are extremely important steps forward. This is a controversial position that has been systematically avoided in the profession for forty years. This is a controversial position that has been systematically avoided in the profession for forty years.

LANGUAGE PROGRAMS THE BRAIN! SLOPPY THINKING LEADS TO DISORGANIZED NEUROCOGNITVE FUNCTIONING.
Unfortunately, I don’t see it changing soon.

ON THE INTERNET:

1.  GORSKI’S WORKING DEFINITION OF RECOVERY
2. SAMHSA’s WORKING DEFINITION OF RECOVERY 


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