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First, let’s look at the results of a meta-analysis of 26 published and unpublished studies with 70 hypothesis tests representing a sample of 9,504 participants.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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Evidence-based Practice: An Elusive Ideal

June 13, 2014

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There is a strong movement toward evidence-based practice and a new buzz-word, evidence-based leadership. is becoming popular. The evidence-based movement involves the complex process of:

1. Figuring out what treatment practices have positive effects on treatment outcomes;

2. Encouraging professionals to use evidence-based principles and practices by encouragingly the use of continuous quality improvement;

3. Promoting a culture of creativity, growth and change within a consistent structure while avoiding cumbersome regulations that fail to add value to the process of patient care.

Evidence-based practice is becoming very complex stuff which, unfortunately, is placing many more levels of complexity between leadership and patient care. The following article reflects, in my opinion, why the evidenced-based movement is struggling.

– The idea of evidence-based practice is becoming way to complex.

– The evidence for what works and what doesn’t work is very weak.

– Different professional cultures fail to effectively communicate and collaborate.

There is the misconception that we know what works and need to force regulations into place that add little or no value to clinical practice.

The comes ideas of evidence-based practice is replacing the idea of simple applied research systems processes once called continuous quality improvement.

It might be helpful to ask both professionals and patients to describe in plain English what they found to be helpful and not helpful in their experience of the treatment process.

For better or worse, here is a description of the complexities of the evidence-based treatment. In my opinion the ideas are far too complex to be practically implemented and the “evidence-based ideal” is placing additional levels of complexity between leadership and patient-care.

The challenge is to simplify the process for real-world application. I still prefer the idea of continuous quality improvement based upon systematic measurement of concrete outcomes close to the the level of patient care that involves patient self-measurement, clinical professional measurement of the same factors, and administrative measurement of treatment plan implementation and incident reporting. The system has been implemented and validated in addiction and mental health programs and requires limited investment.

The USA government has developed and field-tested proven methods for implement CQI in addiction and mental health programs.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2483604/pdf/v007p00149.pdf

Cognitive Restructuring for Addiction is an evidence-based practice that can be implemented in the real world and its effectiveness monitored with CQI methods in a cost effective way. Simple measurement of the patients ability to use the five core cognitive restructuring skills (Thought Management, Feeling Management, Urge/Motivational/Craving Management, Behavioral Recovery Skill Acquisition, and Relationship management. It is a skill based model and the ability of recovery people to learn and use the skills can be measured. Knowing how to use the skills, however, is no guarantee they will be used consistently in recovery. These skills also lend themselves to self-monitoring, an evidence-based cognitive-behavioral therapy technique shown to enhance positive change.

References for Continuous Quality Improvement (CQI)

Deming, W. E. (2000). Out of the crisis. Cambridge, MA: MIT Press.

Gustafson, D., & Hundt, A. (1995). Findings of innovation research applied to quality management principles for health care. Health Care Manager Review, 20(2), 16–33.

Langley, G. L., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). San Francisco, CA: Jossey-Bass. NIATx. (2008). CQI model. Retrieved August 26, 2009, from http://www.niatx.net

GORSKI BOOKS: www.relapse.org

Cognitive Restructuring for Addiction


The AWARE Questionnaire: For Monitoring Relapse Warning Signs

January 8, 2014

AWARE_RWS_LogoBy Terence T. Gorski, Author
January 6, 2014

The risk of relapse is an important factor in determining the type and level of care for addiction treatment. A useful tool called The AWARE Questionnaire has been developed been developed and is in its third revision based upon ongoing use (Miller et al 1996). This questionnaire provides an evidenced based approach for measuring the risk of relapse.

The AWARE Questionnaire (Advance WArning of RElapse) was designed as a measure of the warning signs of relapse, as described by Gorski (Gorski & Miller, 1982).

Gorski’s thirty-seven warning signs of relapse was originally developed as a result of clinical interviews with 117 patient conducted by Gorski.  The patients were chronic stage gamma alcoholics who had completed at least one 28-day residential rehabilitation program for alcoholism and subsequently entered treatment again for alcoholism.

The AWARE Questionnaire (Advance WArning of RElapse) was designed as a measure of the warning signs of relapse, as described by Gorski (Gorski & Miller, 1982). In a prospective study of relapse following outpatient treatment for alcohol abuse or dependence (Miller et al., 1996) the researchers found the AWARE score to be a good predictor of the occurrence of relapse (r = .42, p < .001). With subsequent analyses, the researchers refined the scale from its 37-item original version to the current 28-item scale (version 3.0) (Miller & Harris, 2000).

The items are arranged in the order of occurrence of warning signs, as hypothesized by Gorski. In our prospective study, however, we found no evidence that the warning signs actually occur in this order in real-time (Miller & Harris, 2000). Rather, the total score was the best predictor of impending relapse.

This is a self-report questionnaire that can be filled out by the client. Be sure that the client understands the 1-7 rating scale. When the client has finished, make sure that all items have been answered and none omitted.

Scoring is completed by adding up  the total the numbers circled for all items, but reversing the scoring for the following five items: 8, 14, 20, 24, 26. For these five items only. In other words, if the client circles this number: 1 2 3 4 5 6 7 Add this number to the total score: 7 6 5 4 3 2 1

INTERPRETATION: The higher the score, the more warning signs of relapse are being reported by the client. The range of scores is from 28 (lowest possible score) to 196 (highest possible score). The following table shows the probability of heavy drinking (not just a slip) during the next two months, based on our prospective study of relapse in the first year after treatment (Miller & Harris, 2000).

Probability of Heavy Drinking During the Next Two Months

AWARE
Score

If already drinking
in the prior 2 months

If abstinent during
the prior 2 months

28-55

37%

11%

56-69

62%

21%

70-83

72%

24%

84-97

82%

25%

98-111

86%

28%

112-125

77%

37%

126-168

90%

43%

169-196

>95%

53%

This instrument was developed through research funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA, contract ADM 281-91-0006). It is in the public domain, and may be used without specific permission provided that proper acknowledgment is given to its source. The appropriate citation is Miller & Harris (2000).

References

Gorski, T. F., & Miller, M. (1982). Counseling for relapse prevention. Independence, MO: Herald House – Independence Press.

Miller, W. R., & Harris, R. J. (2000). A simple scale of Gorski’s warning signs for relapse. Journal of Studies on Alcohol, 61, 759-765.

Miller, W. R., Westerberg, V. S., Harris, R. J., & Tonigan, J. S. (1996). What predicts relapse? Prospective testing of antecedent models. Addiction, 91 (Supplement), S155-S171.

AWARE Questionnaire 3.0

Please read the following statements and for each one circle a number, from 1 to 7, to indicate how much this has been true for you recently. Please circle one and only one number for every statement.

Never

Rarely

Some-
times

Fairly
often

Often

Almost
always

Always

1. I feel nervous or unsure of my ability to stay sober.

1

2

3

4

5

6

7

2. I have many problems in my life.

1

2

3

4

5

6

7

3. I tend to overreact or act impulsively.

1

2

3

4

5

6

7

4. I keep to myself and feel lonely.

1

2

3

4

5

6

7

5. I get too focused on one area of my life.

1

2

3

4

5

6

7

6. I feel blue, down, listless, or depressed.

1

2

3

4

5

6

7

7. I engage in wishful thinking.

1

2

3

4

5

6

7

8. The plans that I make succeed.

1

2

3

4

5

6

7

9. I have trouble concentrating and prefer to dream about
how things could be.

1

2

3

4

5

6

7

10. Things don’t work out well for me.

1

2

3

4

5

6

7

11. I feel confused.

1

2

3

4

5

6

7

12. I get irritated or annoyed with my friends.

1

2

3

4

5

6

7

13. I feel angry or frustrated.

1

2

3

4

5

6

7

14. I have good eating habits.

1

2

3

4

5

6

7

Never

Rarely

Some-
times

Fairly
often

Often

Almost
always

Always

15. I feel trapped and stuck, like there is no way out.

1

2

3

4

5

6

7

16. I have trouble sleeping.

1

2

3

4

5

6

7

17. I have long periods of serious depression.

1

2

3

4

5

6

7

18. I don’t really care what happens.

1

2

3

4

5

6

7

19. I feel like things are so bad that I might as well drink.

1

2

3

4

5

6

7

20. I am able to think clearly.

1

2

3

4

5

6

7

21. I feel sorry for myself.

1

2

3

4

5

6

7

22. I think about drinking.

1

2

3

4

5

6

7

23. I lie to other people.

1

2

3

4

5

6

7

24. I feel hopeful and confident.

1

2

3

4

5

6

7

25. I feel angry at the world in general.

1

2

3

4

5

6

7

26. I am doing things to stay sober.

1

2

3

4

5

6

7

27. I am afraid that I am losing my mind.

1

2

3

4

5

6

7

28. I am drinking out of control.

1

2

3

4

5

6

7

SCORING FOR THE AWARE 3.0

For these items, record the number circled

1. ___ 2. ___  3. ___ 4. ___ 5. ___ 6. ____7. ___ 9. ___ 10.__ 11.____ 12.___ 13.___ 15.___ 16.___ 17.___
18.___ 19.___ 21.___ 22.___ 23.___ 25.___ 27.__ 28.___

Subtotal #1: _________

For these 5 items,
reverse the scale
1 = 7; 2=6; 3=5; 4=4; 5=3; 6=2; 7=1;

8. ___ 14. ____ 20. ____ 24. ____ 26 .____

Subtotal #2: _________

Subtotal #1: ______ + Subtotal #2: ______ = AWARE Score:  ______


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

December 31, 2013

20131231-100603.jpg

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


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