Addiction - Treatment Options     Addiction is a complex illness. It is characterized by compulsive, at times uncontrollable drug craving, seeking, and use that persist even in the face of extremely negative consequences. For many people, drug addiction becomes chronic, with relapses possible even after long periods of abstinence. The path to drug addiction begins with the act of taking drugs. Over time, a person's ability to choose not to take drugs can be compromised. Drug seeking becomes compulsive, in large part as a result of the effects of prolonged drug use on brain functioning and, thus, on behavior. The compulsion to use drugs can take over the individual's life. Addiction often involves not only compulsive drug taking but also a wide range of dysfunctional behaviors that can interfere with normal functioning in the family, the workplace, and the broader community. Addiction also can place people at increased risk for a wide variety of other illnesses. These illnesses can be brought on by behaviors, such as poor living and health habits, that often accompany life as an addict, or because of toxic effects of the drugs themselves. Because addiction has so many dimensions and disrupts so many aspects of an individual's life, treatment for this illness is never simple. Drug treatment must help the individual stop using drugs and maintain a drug-free lifestyle, while achieving productive functioning in the family, at work, and in society. Effective drug abuse and addiction treatment programs typically incorporate many compo-nents, each directed to a particular aspect of the illness and its consequences. Three decades of scientific research and clinical practice have yielded a variety of effective approaches to drug addiction treatment. Extensive data document that drug addiction treatment is as effective as are treatments for most other similarly chronic medical conditions. In spite of scientific evidence that establishes the effectiveness of drug abuse treatment, many people believe that treatment is ineffective. In part, this is because of unrealistic expectations. Many people equate addiction with simply using drugs and therefore expect that addiction should be cured quickly, and if it is not, treatment is a failure. In reality, because addiction is a chronic disorder, the ultimate goal of long-term abstinence often requires sustained and repeated treatment episodes. Of course, not all drug abuse treatment is equally effective. Research also has revealed a set of overarching principles that characterize the most effective drug abuse and addiction treatments and their implementation. Principles of Effective Treatment No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society. Treatment needs to be readily available. Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible. Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must address the individual's drug use and any associated medical, psychological, social, vocational, and legal problems. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient at times may require medication, other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical that the treatment approach be appropriate to the individual's age, gender, ethnicity, and culture. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems and needs (see pages 11-49). Research indicates that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding nondrug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual's ability to function in the family and community. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethadol (LAAM) are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate addicts and some patients with co-occurring alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective component of treatment. For patients with mental disorders, both behavioral treatments and medications can be critically important. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive disorders and mental disorders often occur in the same individual, patients presenting for either condition should be assessed and treated for the co-occurrence of the other type of disorder. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions. Possible drug use during treatment must be monitored continuously. Lapses to drug use can occur during treatment. The objective monitoring of a patient's drug and alcohol use during treatment, such as through urinalysis or other tests, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that the individual's treatment plan can be adjusted. Feedback to patients who test positive for illicit drug use is an important element of monitoring. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Counseling can help patients avoid high-risk behavior. Counseling also can help people who are already infected manage their illness. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence. Addiction Treatment in the United States General Categories of Treatment Programs Agonist Maintenance Treatment for opiate addicts usually is conducted in outpatient settings, often called methadone treatment programs. These programs use a long-acting synthetic opiate medication, usually methadone or LAAM, administered orally for a sustained period at a dosage sufficient to prevent opiate withdrawal, block the effects of illicit opiate use, and decrease opiate craving. Patients stabilized on adequate, sustained dosages of methadone or LAAM can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior. Patients stabilized on opiate agonists can engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation. The best, most effective opiate agonist maintenance programs include individual and/or group counseling, as well as provision of, or referral to, other needed medical, psychological, and social services. Outpatient Drug-Free Treatment in the types and intensity of services offered. Such treatment costs less than residential or inpatient treatment and often is more suitable for individuals who are employed or who have extensive social supports. Low-intensity programs may offer little more than drug education and admonition. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient's characteristics and needs. In many outpatient programs, group counseling is emphasized. Some outpatient programs are designed to treat patients who have medical or mental health problems in addition to their drug disorder. Long-Term Residential Treatment provides care 24 hours per day, generally in nonhospital settings. The best-known residential treatment model is the therapeutic community (TC), but residential treatment may also employ other models, such as cognitive-behavioral therapy. TCs are residential programs with planned lengths of stay of 6 to 12 months. TCs focus on the "resocialization" of the individual and use the program's entire "community," including other residents, staff, and the social context, as active components of treatment. Addiction is viewed in the context of an individual's social and psychological deficits, and treatment focuses on developing personal accountability and responsibility and socially productive lives. Treatment is highly structured and can at times be confrontational, with activities designed to help residents examine damaging beliefs, self-concepts, and patterns of behavior and to adopt new, more harmonious and constructive ways to interact with others. Many TCs are quite comprehensive and can include employment training and other support services on site. Compared with patients in other forms of drug treatment, the typical TC resident has more severe problems, with more co-occurring mental health problems and more criminal involvement. Research shows that TCs can be modified to treat individuals with special needs, including adolescents, women, those with severe mental disorders, and individuals in the criminal justice system. Short-Term Residential Programs provide intensive but relatively brief residential treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980's, many began to treat illicit drug abuse and addiction. The original residential treatment model consisted of a 3 to 6 week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as Alcoholics Anonymous. Reduced health care coverage for substance abuse treatment has resulted in a diminished number of these programs, and the average length of stay under managed care review is much shorter than in early programs. Medical Detoxification is a process whereby individuals are systematically withdrawn from addicting drugs in an inpatient or outpatient setting, typically under the care of a physician. Detoxification is sometimes called a distinct treatment modality but is more appropriately considered a precursor of treatment, because it is designed to treat the acute physiological effects of stopping drug use. Medications are available for detoxification from opiates, nicotine, benzodiazepines, alcohol, barbiturates, and other sedatives. In some cases, particularly for the last three types of drugs, detoxification may be a medical necessity, and untreated withdrawal may be medically dangerous or even fatal. Detoxification is a precursor of treatment. Detoxification is not designed to address the psychological, social, and behavioral problems associated with addiction and therefore does not typically produce lasting behavioral changes necessary for recovery. Detoxification is most useful when it incorporates formal processes of assessment and referral to subsequent drug addiction treatment. Relapse Prevention, a cognitive-behavioral therapy, was developed for the treatment of problem drinking and adapted later for cocaine addicts. Cognitive-behavioral strategies are based on the theory that learning processes play a critical role in the development of maladaptive behavioral patterns. Individuals learn to identify and correct problematic behaviors. Relapse prevention encompasses several cognitive-behavioral strategies that facilitate abstinence as well as provide help for people who experience relapse. The relapse prevention approach to the treatment of cocaine addiction consists of a collection of strategies intended to enhance self-control. Specific techniques include exploring the positive and negative consequences of continued use, self-monitoring to recognize drug cravings early on and to identify high-risk situations for use, and developing strategies for coping with and avoiding high-risk situations and the desire to use. A central element of this treatment is anticipating the problems patients are likely to meet and helping them develop effective coping strategies. Research indicates that the skills individuals learn through relapse prevention therapy remain after the completion of treatment. In one study, most people receiving this cognitive-behavioral approach maintained the gains they made in treatment throughout the year following treatment. Dual Disorders Recovery Counseling OVERVIEW, DESCRIPTION, AND RATIONALE General Description of Approach Dual disorders recovery counseling (DDRC) is an integrated approach to treatment of patients with drug use disorders and comorbid psychiatric disorders. The DDRC model, which integrates individual and group addiction counseling approaches with psychiatric interventions, attempts to balance the focus of treatment so that both the patient's addiction and psychiatric issues are addressed. The DDRC model is based on the assumption that there are several treatment phases that patients may go through. These phases are rough guidelines delineating some typical issues patients deal with and include: Phase 1—Engagement and Stabilization. In this phase, patients are persuaded, motivated, or involuntarily committed to treatment. The main goal of this phase is to help stabilize the acute symptoms of the psychiatric illness and/or the drug use disorder. Another important goal is to motivate patients to continue in treatment once the acute crisis is stabilized or the involuntary commitment expires. Dealing with ambivalence regarding recovery, working through denial of either or both illnesses, and becoming motivated for continued care are other important goals during this phase. This phase usually takes several weeks, but for some patients it takes longer to become engaged in recovery and to stabilize from acute effects of their dual disorders. Phase 2—Early Recovery. This phase involves learning to cope with desires to use chemicals; avoiding or coping with people, places, and things that represent high-risk addiction relapse factors; learning to cope with psychiatric symptoms; getting involved in support groups, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), Rational Recovery (RR), Dual Recovery Anonymous, or mental health support groups; getting the family involved (if indicated); beginning to build structure into life; and identifying problems to work on in recovery. This phase roughly involves the first 3 months following stabilization. However, some patients take much longer in this phase because they do not comply with treatment, continue to abuse drugs, experience exacerbations of psychiatric symptomology, or experience serious psychosocial problems or crises. Phase 3—Middle Recovery. In this phase, patients continue working on issues from the previous phase as needed. In addition, patients learn to develop or improve coping skills to deal with intrapersonal and interpersonal issues. Examples of intrapersonal skills include coping with negative affect (anger, depression, emptiness, anxiety) and coping with maladaptive beliefs or thinking. Interpersonal issues that may be addressed during this phase include making amends, improving communication or relationship skills, and further developing social and recovery support systems. This phase also focuses on helping patients cope with persistent symptoms of psychiatric illness; drug use lapses, relapses, or setbacks; and crises related to the psychiatric disorder. It also focuses on helping identify and manage relapse warning signs and high-risk relapse factors related to either illness. The middle recovery phase involves months 4 through 12, although some patients never get much beyond early recovery even after a long time in treatment. Patients who are treated for an initial acute episode of psychiatric illness with pharmacotherapy in addition to DDRC and who do not have a recurrent or persistent mental illness may be tapered off medications during this phase. Patients are usually not tapered off medications until they have several months or longer of significant improvement in psychiatric symptomology. Phase 4—Late Recovery. This phase, also referred to as the "maintenance phase" of recovery, involves continued work on issues addressed in the middle phase of recovery and work on other clinical issues that emerge. Important intrapersonal or interpersonal issues may be explored in greater depth during this phase for patients who have continued abstinence and remained relatively free of major psychiatric symptoms. This phase continues beyond year 1. Many patients with chronic or persistent forms of psychiatric illness (e.g., schizophrenia, bipolar disease, recurrent major depression), or severe personality disorders such as borderline personality disorder, often continue active involvement in treatment. Treatment during this phase may involve maintenance pharmacotherapy, supportive DDRC counseling, or some specific form of psychotherapy (e.g., interpersonal psychotherapy). Involvement in support groups continues during this phase of recovery as well. Goals and Objectives of Approach Achieving and maintaining abstinence from alcohol or other drugs of abuse or, for patients unable or unwilling to work toward total abstinence, reducing the amount and frequency of use and concomitant biopsychosocial sequelae associated with drug use disorders. Stabilizing acute psychiatric symptoms. Resolving or reducing problems and improving physical, emotional, social, family, interpersonal, occupational, academic, spiritual, financial, and legal functioning. Working toward positive lifestyle change. Early intervention in the process of relapse to either the addiction or the psychiatric disorder.
Theoretical Rationale/Mechanism of Action
	The DDRC counseling approach involves a broad range of interventions: Motivating patients to seek detoxification or inpatient treatment if symptoms warrant, and sometimes facilitating an involuntary commitment for psychiatric care. Educating patients about psychiatric illness, addictive illness, treatment, and the recovery process. Supporting patients' efforts at recovery and providing a sense of hope regarding positive change. Referring patients for other needed services (case management, medical, social, vocational, economic needs). Helping patients increase self-awareness so that information regarding dual disorders can be personalized. Helping patients identify problems and areas of change. Helping patients develop and improve problem solving ability and develop recovery coping skills. Facilitating pharmacotherapy evaluation and compliance. (This requires close collaboration with the team psychiatrist.)
Agent of Change
	The DDRC model assumes that change may occur as a result of the patient-counselor relationship and the team relationship (i.e., counselor, psychiatrist, psychologist, nurse, or other professionals such as case manager or family therapist). A positive therapeutic alliance is seen as critical in helping patients become involved and stay involved in the recovery process. Community support systems, professional treatment groups, and self-help programs also serve as possible agents of positive change for dually diagnosed patients. For the more chronically and persistently mentally ill patients, a case manager may also function as an important agent in the change process. Although patients have to work on a number of intrapersonal and interpersonal issues as part of long-term recovery, medications can facilitate this process by attenuating acute symptoms, improving mood, or improving cognitive abilities or impulse control. Thus, medications may eliminate or reduce symptoms as well as help patients become more able to address problems during counseling sessions. A severely depressed patient may be unable to focus on learning cognitive or behavioral interventions until he or she experiences a certain degree of remission from symptoms of depression; a floridly psychotic patient will not be able to focus on abstinence from drugs until the psychotic symptoms are under control.
Conception of Drug Abuse/ Addiction, Causative Factors
	Both psychiatric and addictive illnesses are viewed as biopsychosocial disorders. These disorders or diseases are caused or maintained by a variety of biological, psychological, and cultural/social factors. The degree of influence of specific factors may vary among psychiatric disorders. This DDRC model assumes that there are several possible relationships between psychiatric illness and addiction (Daley et al. 1993; Meyer 1986). Axis I and Axis II psychopathology may serve as a risk factor for addictive disorders (e.g., the odds of having an addictive disorder among individuals with a mental illness is 2.7 according to the National Institute of Mental Health's Epidemiologic Catchment Area [ECA] survey). Some psychiatric patients may be more vulnerable than others to the adverse effects of alcohol or other drugs. Addiction may serve as a risk factor for psychiatric illness (e.g., the odds of having a psychiatric disorder among those with a drug use disorder is 4.5 according to the ECA survey). The use of drugs can precipitate an underlying psychiatric condition (e.g., PCP or cocaine use may trigger a first manic episode in a vulnerable individual). Psychopathology may modify the course of an addictive disorder in terms of: a. Rapidity of course (earlier age depressives experience addiction problems earlier; male-limited alcoholics [25 percent] with antisocial behaviors have earlier onset of addiction compared with milieu-limited alcoholics [Cloninger 1987]). b. Response to treatment (patients with antisocial or borderline personality disorder often drop out of treatment early). c. Symptom picture and long-term outcome (high psychiatric severity patients as measured by the Addiction Severity Index (ASI) do worse than low psychiatric severity patients; there is a strong association between relapse and psychiatric impairment among opiate addicts and some association between relapse and psychiatric impairment among alcoholics [Catalano et al. 1988; McLellan et al. 1985]). Psychiatric symptoms may develop in the course of chronic intoxications (e.g., psychosis may follow PCP use or chronic stimulant use; suicidal tendencies and depression may follow a cocaine crash). Psychiatric symptoms may emerge as a consequence of chronic use of drugs or a relapse (e.g., depression may be caused by an awareness of the losses associated with addiction; depression may follow a drug or alcohol relapse). Drug-using behavior and psychopathological symptoms (whether antecedent or consequent) will become meaningfully linked over the course of time. The addictive disorder and the psychiatric disorder can develop at different points in time and not be linked (e.g., a bipolar patient may become hooked on drugs years after being stable from a manic disorder; an alcoholic may develop panic disorder or major depression long after being sober). Symptoms of one disorder can contribute to relapse of the other disorder (e.g., increased anxiety or hallucinations may lead the patient to alcohol or other drug use to ameliorate symptoms; a cocaine or alcohol binge may lead to depressive symptoms). CONTRAST TO OTHER COUNSELING APPROACHES Most Similar Counseling Approaches
	The DDRC model is most similar to various aspects of several models of treatment used in addiction counseling, mental health counseling, or both. These include individual and group addiction recovery models, the psychoeducational (PE) model, the relapse prevention (RP) model, the cognitive-behavioral model, and the interpersonal model.
Most Dissimilar Counseling Approaches
	The DDRC model is dissimilar to the various forms of dynamic therapies.
FORMAT
Modalities of Treatment
	The DDRC model can be used in a variety of group treatments and in individual treatment. It can also be adapted to family treatment.
Ideal Treatment Setting
	The DDRC model was primarily developed for use in a mental health or dual disorders treatment setting. It can be used throughout the continuum of care in inpatient, other residential, partial hospital, and outpatient settings. The specific areas of focus will depend on each patient's presenting problems and symptoms and the treatment setting. Certain aspects of this model could be adapted and used in addiction treatment settings provided that appropriate training, supervision, and consultation are available for the counselor.
Duration of Treatment
	Acute inpatient dual-diagnosis treatment usually lasts up to 3 weeks. Longer term specialty residential treatment programs may last from several months to a year or more. Partial hospitalization programs usually last from 6 to 12 months. Outpatient treatment lasts 6 months or longer. Recurrent conditions, such as certain depressive disorders and bipolar illness, as well as persistent mental illness such as schizophrenia, typically require ongoing participation in maintenance pharmacotherapy and some type of supportive counseling.
Compatibility With Other Treatments
	The DDRC model is very compatible with pharmacotherapy and family treatment. Many patients require medication to treat psychiatric symptoms. Therefore, medication compliance, the perception of taking medications as a recovering alcoholic or addict, and potential adverse effects of alcohol or other drugs on medication efficacy are important issues to discuss with the patient. Family participation in assessment and treatment is viewed as important and compatible with the DDRC model. The family can: Help provide important information in the assessment process. Provide support to the recovering patient. Address their own questions, concerns, and reactions to coping with the dually diagnosed patient. Address their own problems and issues in treatment sessions or self-help programs. Help identify early signs of addiction relapse or psychiatric recurrence and point these out to the recovering dually diagnosed family member. A combination of family PE programs, family counseling sessions, and family support programs can be used to help families. Referrals for assessment of serious problems (psychiatric, drug abuse, behavioral) among specific family members can also be initiated as necessary (e.g., a child of a patient who is suicidal, very depressed, or getting into trouble at school can be referred for a psychiatric evaluation).
Role of Self-Help Programs
	Self-help programs are very important in the DDRC model of treatment. All patients are educated regarding self-help programs and linked up to specific programs. The self-help programs recommended may include any of the following for a given patient: AA, NA, CA, and other addiction support groups such as RR or Women for Sobriety; dual-recovery support groups; and mental health support groups. However, this model does not assume that a patient cannot recover without involvement in a 12-step group or that failure to attend 12-step groups is a sign of resistance. The DDRC model also assumes that some patients may use some of the tools of recovery of self-help programs even if they do not attend meetings. Sponsorship, recovery literature, slogans, and recovery clubs are also seen as very helpful aspects of recovery for dually diagnosed patients.
COUNSELOR CHARACTERISTICS AND TRAINING
Educational Requirements
	The educational requirements are variable for inpatient staff and depend on the professional discipline's requirements. Formal education of inpatient staff include M.D., Ph.D., master's, bachelor's, and associate degrees. Training in fields such as nursing may vary as well and include M.S.N., B.S.N., R.N., and L.P.N. Outpatient therapists tend to have at least a master's degree or higher and function more autonomously than inpatient staff.
Training, Credentials, and Experience Required
	To effectively provide counseling services to dually diagnosed patients, the counselor needs to have a broad knowledge of assessment and treatment of dual disorders. Specific areas with which the counselor should be familiar, at a minimum, include the following: Psychiatric illnesses (types, causes, symptoms, and effects). Drug use disorders (trends in drug abuse; types and effects of various drugs; causes, symptoms, and effects of addiction). The relationship between the psychiatric illness and drug use. The recovery process for dual disorders. Self-help programs (for addiction, mental health disorders, and dual disorders). Family issues in treatment and recovery. Relapse (precipitants, warning signs, and RP strategies for both disorders). Specialized psychosocial treatment approaches for various psychiatric disorders (e.g., treatments for posttraumatic stress disorder, obsessive-compulsive disorder). Pharmacotherapy. The continuum of care (for both addiction and psychiatric illnesses). Local community resources. The process of involuntary hospitalization. Motivational counseling strategies. Ways to deal with ambivalent patients and those who do not want help. Strategies to deal with refractory or treatment-resistant patients with chronic forms of mental illness. How to use bibliotherapeutic assignments to facilitate the patient's recovery. The counselor must be able to develop a therapeutic alliance with a broad range of patients who manifest many different disorders and differing abilities to utilize professional treatment. This requires awareness of the counselor's own issues, biases, limitations, and strengths, as well as the counselor's willingness to examine his or her own reactions to different patients. The counselor needs to be able to effectively network with other service providers since many of these dually diagnosed patients have multiple psychosocial needs and problems. Because crises often arise, the counselor must also be conversant with crisis intervention approaches. The ability to work with a team is also essential in all treatment contexts. Experience with addicts and mental health patients is the ideal. However, if a counselor is trained in one field and has access to additional training and supervision in another, it is possible to expand knowledge and skills and work effectively with dually diagnosed patients.
Counselor's Recovery Status
	If a counselor has the training, knowledge, and experiential background in working with psychiatric patients and with addicts, a personal history of recovery can be helpful. Although self-disclosure is sometimes appropriate, in general, the counselor providing treatment should share less of his or her own recovery experience than is typically shared in the more traditional addiction counseling model.
Ideal Personal Characteristics of Counselor
	Hope and optimism for the patient's recovery; a high degree of empathy, patience, and tolerance; flexibility; an ability to enjoy working with difficult patients; a realistic perspective on change and steps toward success; a low need to control the patient; an ability to engage the patient yet be able to detach; and an ability to utilize a multiplicity of treatment interventions rather than relying on a single way of counseling are important characteristics and qualities that counselors need.
Counselor's Behaviors Prescribed
	The DDRC approach requires a broad range of behaviors on the part of the counselor. Specific behaviors are mediated by the severity of the patient's symptoms and his or her related needs and problems. The counselor's behaviors may include any of the following: Providing information and education. Challenging denial and self-destructive behaviors. (Confrontation is modified to take into account the patient's ego strength and ability to tolerate confrontation.) Providing realistic feedback on problems and progress in treatment. Encouraging and monitoring abstinence. Helping the patient get involved in self-help groups. Helping the patient identify, prioritize, and work on problems and recovery issues. Monitoring addiction recovery issues. Monitoring target psychiatric symptoms (suicidality, mood symptoms, thought disorder symptoms, or problem behaviors). Helping the patient develop specific RP skills (e.g., coping with alcohol or other drug cravings, refusing offers to get high, challenging faulty thinking, coping with negative affect, improving interpersonal behaviors, managing relapse warning signs). Advocating on behalf of the patient and facilitating inpatient admission when needed. Facilitating the use of community resources or services. Developing therapeutic assignments aimed at helping the patient reach a goal or make a specific change. Following up when a patient fails to follow through with treatment. Offering support, encouragement, and outreach.
Counselor's Behaviors Proscribed
	The DDRC counselor does not typically interpret the patient's behaviors or motivation. The focus is more on understanding and coping with practical issues related to the dual disorders and current functioning. The counselor avoids extensive exploration of past traumas during the early phase of recovery because this can lead to avoidance of addressing the drug use disorder and can increase the patient's anxiety. The DDRC counselor also minimizes time spent on coaddiction issues since this can deflect from the drug use problem and raise anxiety. Harsh confrontation is avoided because it can adversely impact on the patient's sense of self and can drive the patient away from treatment. Confrontation can be used, but it should be done in a caring, nonjudgmental, nonpunitive, and reality-oriented manner.
Recommended Supervision
	The goals of supervision are to help the counselor: Increase knowledge of dual disorders counseling. Improve special counseling skills. Deal with personal issues or reactions that impede therapeutic alliance or progress (e.g., anger toward a patient who relapses, negative reactions to a patient with a personality disorder). Use personal strengths in the counseling process (e.g., personal experiences, humor). Maintain a reasonable therapeutic focus on the patient's addiction and mental health disorder. Determine strategies to work through impasses in counseling. A variety of formats can be used in supervising the DDRC approach: Joint discussion of individual counseling cases, family sessions, or group sessions. Review of clinical notes and treatment plans. Live observation of counseling sessions. Review and discussion of audiotapes or videotapes of counseling sessions. Cotherapy sessions. Group supervision with other counselors in which individual, family, or groups are reviewed or in which clinical concerns are shared and explored. One of the most helpful but time-intensive formats is where the counselor can be "seen in action." This provides tremendous opportunities to identify personal or professional areas that need further attention. This is especially helpful to less experienced counselors. Once a counselor works through anxiety about being scrutinized, he or she usually finds this process helpful. Counselors should receive specific feedback regarding their counseling. This includes positive reinforcement for good work as well as critical feedback on areas of weakness. For example, a group counselor can benefit from feedback pointing out that he or she talks too much in the group sessions or tells patients how to cope with a recovery issue before eliciting their ideas on coping strategies. The use of adherence scales in some clinical research protocols is an excellent way of providing specific feedback on a particular treatment session. The counselor is rated on the performance of specific interventions as well as the quality of those interventions. The major drawback is that tapes of specific treatment sessions have to be reviewed in detail, a time-consuming process.
CLIENT-COUNSELOR RELATIONSHIP
What Is the Counselor's Role?
	As evidenced by the list of counselor behaviors noted earlier, many roles are assumed in DDRC: educator, collaborator, adviser, advocate, and problemsolver.
Who Talks More?
	Generally, the patient talks the most during individual DDRC sessions. In PE groups, the counselor is usually very active in providing education to the group. However, patients are encouraged to ask questions, share personal experiences related to the group topic, and express feelings.
How Directive Is the Counselor?
	In DDRC, the counselor may be very directive and active with one patient and less directive and active with another. The approach must be individualized and take into account each patient's strengths, abilities, and deficits. However, the counselor is generally more directive than in traditional mental health counseling, particularly in relation to continued drug use and relapse setups and in pointing out other self-defeating behavior patterns.
Therapeutic Alliance
	A good therapeutic alliance (TA) facilitates recovery and is based on the counselor's ability to connect with the patient, respect differences, show empathy, use humor, and understand the inner world of the patient. Listening, providing information, being supportive and encouraging, and being up front and directive can help build the TA. A poor TA often shows in a patient's missed appointments or failure to comply with treatment. Discussing common problems in recovery and acknowledging specific problems between the counselor and the patient can help improve a poor alliance. Calling patients who drop out of treatment early and inquiring as to whether they think a new treatment plan can help may also help correct a poor TA. Discussing specific cases in supervision can help the counselor identify causes of a poor TA and develop strategies to correct the problem. As a last resort, a case may be transferred to another counselor if the client-counselor relationship is such that a TA cannot be formed.
TARGET POPULATIONS
Clients Best Suited for This Counseling Approach
	The DDRC approach can be adapted for virtually any type of addiction, mental health disorder, or combination of dual disorders. However, it is best suited for mood, anxiety, schizophrenic, personality, adjustment, and other addictive disorders, in combination with alcohol or other drug addiction.
Clients Poorly Suited for This Counseling Approach
	Clients with mental retardation, organic brain syndromes, head injuries, and more severe forms of thought disorders are less suited for this counseling approach.
ASSESSMENT
	The initial assessment involves a combination of the following: psychiatric evaluation, mental status exam, ASI, physical examination, laboratory work, and urinalysis. Patient and collateral interviews and review of previous records are part of the assessment process. The assessment process for inpatient treatment is more extensive and involved than assessment for outpatient care. An assessment covers the following areas: review of current problems, symptoms and reasons for referral, current and past psychiatric history, current and past drug use and abuse, history of treatment, mental status exam, medical history, family history, developmental history (e.g., development, school, work), current stressors, social support system, current and past suicidality, current and past aggressiveness or homicidality, and other areas based on the judgment of the evaluation team (e.g., relapse history, patterns of hospitalization). The drug abuse history should include specific drugs used (past and present), patterns of use (frequency, quantity, methods), context of use, and consequence of use (medical, psychiatric, family, legal, occupational, spiritual, financial). It should also include review of drug abuse or addiction symptoms (e.g., loss of control, obsession or preoccupation, tolerance changes, inability to abstain despite repeated attempts, withdrawal syndromes, continuation of use despite psychosocial problems, impairment caused by intoxications). Clinical interviews can be used as well as specific assessment instruments, such as the ASI, Drug Use Screening Inventory, Drug Abuse Screening Test, Milligan Alcoholism Screening Test, or other addiction-specific instruments. Regular or random urinalysis or breathalyzers can be used to monitor drug use, particularly in the early phases of recovery. Specific instruments may also be used for psychiatric disorders to obtain objective and subjective data. These may be administered by a professional (e.g., certain personality disorder interviews), or they may be completed by the patient at different points in time (e.g., Beck Depression or Anxiety Inventories, Zung Depression Inventory). These can also be used to gather baseline data and measure change in symptoms over time. Completing recovery workbook assignments or the drug abuse problem checklist (see Appendix for examples) is an additional way of assessing a patient's perception of his or her problem areas related to drug use. The counselor can use these tools to identify specific areas for focus in individual DDRC sessions.
SESSION FORMAT AND CONTENT
Format for a Typical Session
	An individual DDRC session reviews addiction and mental health recovery issues. The time spent in a given session on addiction or mental health issues varies and depends on the specific issues and recovery status of a particular patient. For example, even if a depressed alcoholic patient were sober 9 months, the counselor may briefly inquire about any number of addiction recovery issues (e.g., cravings or close calls, actual episodes of use, involvement in self-help group meetings, discussions with sponsors). Or, if an addicted patient's depression were improved, the counselor would inquire about the typical symptoms this patient had prior to coming to treatment (e.g., mood, suicidality, energy). Any crisis issues would be attended to as well. The majority of time spent during the individual counseling session (unless a crisis takes up the session) focuses on the patient's agenda. The patient is usually asked at the beginning of the session what concern or problem he or she wants to focus on in that day's session. The problem or concern should be one that the patient has identified as an important part of his or her treatment plan. In relation to the problem or issues identified, the counselor helps the patient explore this to better understand and cope with it. Coping strategies are especially important since the session should be a purposeful one aimed at helping the patient work toward change. During the course of the DDRC session, any "live" material that is relevant to the patient's dual disorders or recovery can be processed. For example, if the patient gives evidence of maladaptive thinking in the session that is contributing to anxiety or depressive symptoms (jumping to conclusions or focusing only on the negative), this can be pointed out and discussed in the context of the patient's problems. The DDRC session ends with a review of what the patient will be doing between this and the next session relating to his or her recovery. It is helpful for the counselor to provide encouragement and positive feedback at the end of each session for the work that the patient accomplished and for the effort put forth. Reading, writing, or behavioral assignments may be given at the end of the session. The goal of these therapeutic assignments is to have the patient actively work on problems and issues between counseling sessions.
Several Typical Session Topics or Themes
	Medication visits and special consultations are held with the counselor and psychiatrist. These ensure integrated care, help prevent the patient from "splitting" the counselor and psychiatrist, and enhance ongoing team communication. These visits are usually brief and focus on medication issues or treatment compliance issues. The counselor gives the psychiatrist an update on treatment prior to the joint meeting. The counselor adds input during the session as needed. The psychiatrist and counselor can strategize after the meeting regarding therapeutic interventions.
Session Structure
	PE group sessions can easily be adapted to inpatient, residential, partial hospital, or outpatient settings. A specific PE group treatment curriculum can be developed for use in any treatment setting. PE group programs can vary in terms of number of sessions offered per week and total number of sessions offered during the treatment course. For example, patients in the author's various inpatient dual disorders programs participate in up to five PE groups each week. Outpatients may attend weekly PE groups for up to several months. PE groups provide information on important recovery topics to patients and help them begin to explore different coping strategies to handle the various demands of recovery. It is important to try to balance the focus on problems and coping strategies so that patients can begin to be exposed to positive strategies that can help them deal with their issues and problems. PE group sessions are structured around a specific recovery issue or theme. The specific themes reviewed depend on the total number of sessions available for the patient. Each PE group is structured as follows (see Appendix for sample group sessions): Topic or recovery theme. Objectives or purpose of PE group session. Major points to review and methods of covering the material. PE group handouts to be read aloud, completed, and discussed in group, allowing members to relate personally to the PE topic. The group leader reviews the material interactively, so that patients can ask questions, share personal experiences related to the material covered, and provide help and support to one another. Outpatient and partial hospital PE group sessions usually last 1-1/2 hours; inpatient PE group sessions usually last 1 hour. Prior to reviewing the PE group topic material in outpatient groups, the leader first takes time to discuss whether or not any patients have had setbacks, lapses or relapses, close calls, strong cravings to use drugs, or any other pressing issue since the last session. Some time is spent discussing these matters prior to reviewing the group curriculum. Specific topics or recovery themes explored in PE groups include: Understanding psychiatric illnesses (causes, symptoms, and treatment) and addiction (causes, symptoms, and treatment). Understanding relationships between drug use and psychiatric disorders. Denial of dual disorders and common roadblocks in recovery. Medical and psychiatric effects of drugs and addiction. Psychosocial effects of dual disorders. The recovery process for dual disorders. Medication education. Coping with cravings and desires to use alcohol or other drugs. Coping with anger, anxiety, and worry. Coping with boredom. Discovering ways to use leisure time. Coping with depression. Coping with guilt and shame. Family issues (e.g., impact of dual disorders, recovery resources, family treatment). Developing a sober recovery support system. Coping with pressures to get high or to stop taking psychiatric medications. Changing negative or maladaptive thinking. Spirituality in recovery. Joining AA/NA/CA, mental health, and dual recovery support groups and recovery clubs. Recovery prevention (warning signs, high-risk factors). Followup inpatient care. Understanding and using psychotherapy and counseling. This material can also be modified and adapted for use in 90-minute weekly multiple family groups (MFGs) or for use in monthly, daily, or halfday PE workshops attended by patients and families or significant others (SOs). Any of the above themes as well as others may be explored in individual DDRC sessions.
Strategies for Dealing With Common Clinical Problems
	Lateness is discussed directly with the patient to determine the reasons for it, and strategies are discussed so the patient can better comply with the treatment schedule. Chronic patterns of lateness may be generalized as indicative of broader patterns of difficulty with responsibility or as part of a self-defeating pattern of behavior. Missed sessions are discussed with the patient to determine why and to work through any resistance the patient has. A patient who fails to show or who calls to cancel an appointment is usually called by the clinician or sent a friendly note in the mail offering another appointment or asking the patient to call so an appointment can be rescheduled. Interventions with patients who come to sessions under the influence are dealt with in a number of different ways depending on their condition. Detoxification and inpatient hospitalization may be arranged in severe cases involving potential withdrawal and florid psychiatric symptoms. In other cases, crisis intervention may be offered or the patient may be helped to make arrangements to go home and return for another appointment when not under the influence of chemicals. Generally, these situations are handled in the most appropriate clinical manner. Limits may be set without coming across as punitive or judgmental. Contracts noting a patient's specific issues (lateness, missed sessions, failure to complete therapeutic assignments, coming to sessions under the influence of chemicals) may also be created.
Strategies for Dealing With Denial, Resistance, or Poor Motivation
	Treatment sessions deal with ambivalence of patients regarding ongoing participation in treatment. The counselor attempts to normalize and validate ambivalence or denial in the context of addiction or psychiatric illness. Education, support, the use of therapeutic assignments, sessions with the team to discuss symptoms and behaviors of the patient, and sessions involving collaterals such as family or SOs may be used to help deal with denial and resistance. Generally, any resistance is "grist for the therapeutic mill" and is explored in treatment sessions. Poor motivation is usually seen as a manifestation of illness, particularly with more severely addicted or psychiatrically impaired patients. Personality issues also greatly contribute to resistance and poor motivation.
Strategies for Dealing With Crises
	A very flexible approach is needed in dealing with crisis since dually diagnosed patients often experience exacerbations of illness. In more severe cases, voluntary or involuntary hospitalization may be sought to help stabilize a patient. Additional face-to-face sessions with any member(s) of the treatment team, including the case manager for persistently mentally ill patients, may also be held. In some instances, supportive sessions via telephone are conducted. All patients are given an emergency phone number that can be called 24 hours a day, 7 days a week, and all patients are instructed on how and when to use the psychiatric emergency room.
Counselor's Response to Slips and Relapses
	The counselor typically approaches lapses or relapses as opportunities for the patient to learn about relapse precipitants or setups. All lapses and relapses to drug use are explored in an attempt to identify warning signs. Strategies are discussed to help the patient better prepare for recovery. Additional sessions or telephone contacts may be used to help the patient stabilize from some relapses. Inpatient detoxification or rehabilitation programs may be arranged in instances where the relapse is severe and cannot be interrupted with the help and support of counseling along with self-help programs (e.g., AA, NA, CA). Drug use relapses are processed in terms of their impact on psychiatric symptoms and recovery from dual disorders. If a patient is on medication, the possible interactions with alcohol or nonprescribed drugs are discussed. Psychiatric relapses are discussed in terms of warning signs and causes to help the patient determine what may have contributed to the relapse. Additional sessions with the counselor or other members of the treatment team may be provided to help the patient stabilize. Medication adjustments also may be made, depending on the symptoms experienced by the patient. When psychiatric symptoms are life threatening or cause significant impairment in functioning, an inpatient hospitalization may be arranged.
ROLE OF SIGNIFICANT OTHERS IN TREATMENT
	Families are often adversely affected by a patient with dual disorders and have many questions and concerns regarding their ill member. Family members can have a significant impact on the patient and can be either an excellent source of support or an additional stress during the patient's recovery. Counselors are encouraged to include families in assessment and treatment sessions. PE programs, MFGs, and individual family sessions may be used. Patients in need of family therapy may be referred to a social worker or therapist conversant with family therapy approaches if the DDRC counselor is not familiar with family therapy. Particular attention is paid to children of patients so that assessments can be arranged if a counselor feels that a psychiatric evaluation is warranted for a patient's child. PE programs provide helpful information on dual disorders and recovery and encourage families to attend support groups for mental health disorders or addictive disorders (e.g., Nar-Anon or Al-Anon). MFGs that include the patient and his or her family members and that combine open discussion with some focus on acquiring education can be offered on a weekly or monthly basis. Mutual help and support can be shared among members of different families. Individual family sessions can be used to focus on specific issues and problems of a particular family. The counselor also works with the patient on strategies to improve communication and relationships with family members even when they are not directly involved in treatment sessions or recovery group meetings.

The CENAPS® Model of Relapse Prevention Therapy (CMRPT®)
OVERVIEW, DESCRIPTION, AND RATIONALE
General Description of Approach
	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.
Goals and Objectives of Approach
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: Assessment. Warning sign identification. Warning sign management. Recovery planning. 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.
	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.
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: Thinking. Feeling. Acting. The primary social domains are: Work. Friendship. 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.
CONTRAST TO OTHER COUNSELING APPROACHES
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.
Most Dissimilar Counseling Approaches
	The CMRPT is most dissimiliar to the following types of therapy: Therapies that view chemical addiction as a symptom of an underlying mental or psychological problem. 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. Nondirective or client-centered approaches. 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.
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.
Group Rules.
	The following rules are used as part of the problem solving group process. 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. 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. 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. No swearing, putting down, fighting, or threats of violence are permitted. The threat of violence is considered as good as the act. 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. Anyone who decides to leave the group must inform the group (in person) prior to departure. 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.
Group Responsibilities.
	Group members agree to fulfill the following basic group responsibilities: Offer their reaction at the beginning of each session. Volunteer to work on a personal issue in each group session. Complete all assignments and report to the group on what was learned. Listen to other group members when they present problems. Ask questions to help clarify the problem or proposed solution. Offer feedback about the problem and the group member presenting the problem. When appropriate, share personal experiences with similar problems. 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.
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. 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. Opening procedure (5 minutes). The counselor sets the climate for the group, establishes leadership, and helps clients warm up to the group process. 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. 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. 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?   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. 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. 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. 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.
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.
Duration of Treatment
	The CMRPT can be administered in a variety of settings over a variable number of sessions.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Ideal Personal Characteristics of Counselor