Relapse prevention strategies and interventions

Relapse prevention therapy breaks down the chemical dependency recovery process into specific tasks and skills, which patients must learn in order to recover; it also shows patients how to recognize when they are beginning to relapse, and how to change before they start using alcohol or drugs again (Gorski and Kelley, 2003).

In order to understand the process of relapse prevention, we will first look at the phenomena of chemical dependence, and its associated behaviors, and the phenomena of relapse, in order to be able to then look at the various ways of tackling these behaviors to induce relapse prevention in the patients.

What is Chemical Dependency/Chemical Addiction?

Chemical dependency is a disease caused by the use of alcohol and/or drugs, causing changes in a person's body, mind, and behavior: as a result of the disease of chemical dependency, people are unable to control the use of alcohol and/or drugs, despite the bad things that happen when they use (Gorski and Kelley, 2003). Chemical dependency occurs most frequently in people who have a family history of the disease, and as the disease process progresses, recovery becomes more difficult; chemical dependency may cause death if the person does not completely abstain from using alcohol and other mood-altering drugs (Gorski and Kelley, 2003).

Effects of Chemical Dependency

The problems of chemical dependency that affect people when they use alcohol or drugs, and even after they have stopped using, include the following: Malnutrition and metabolic dysfunction; Liver disease and other medical complications; Brain dysfunction; Addictive preoccupation; Adverse Social consequences and Criminal behaviors (Gorski and Kelley, 2003).

The conditions just described combine and interfere with the ability to think clearly, control feelings, and regulate behaviors, especially under stress, as alcohol and drug dependency damages the basic personality traits that are formed before the addictive use of alcohol or drugs (Gorski and Kelley, 2003). Dependency on alcohol or other drugs systemically destroys meaning and purpose in life as the addiction gets worse and worse (Gorski and Kelley, 2003).

Treatment for Chemical Dependency

As dependency on alcohol or other drugs creates problems in a person's physical, psychological, and social functioning, treatment must be designed to work in all three areas (Gorski and Kelley, 2003). The worse the damage in each area, the greater the chance of relapse and the greater the chance of return to old behaviors, for instance, criminal actions and/or the use of alcohol or drugs (Gorski and Kelley, 2003). Total abstinence (not using any alcohol and drugs) plus personality and lifestyle changes are essential for full recovery (Gorski and Kelley, 2003).

Essentially, the type and intensity of treatment depend on the patient's: current physical, psychological and social problems; stage and type of addiction(s); stage of recovery; personality traits and social skills before the onset of addiction, and other factors in life that cause stress (Gorski and Kelley, 2003).

Chemical dependency is a chronic condition that has a tendency toward relapse, hence abstinence from alcohol and other mood-altering drugs is essential in the treatment of chemical dependency (Gorski and Kelley, 2003).

It is a fact that many chemically dependent people who exhibit criminal behaviors were raised in families that did not provide proper support, guidance, and values, which caused them to develop self-defeating personality styles that interfere with their ability to recover, where personality is the habitual way of thinking, feeling, acting, and relating to others that develops in childhood and continues in adult life which develops as a result of an interaction between genetically inherited traits and family environment (Gorski and Kelley, 2003).

Growing up in a dysfunctional family causes a person to have a distorted view of the world: he or she learns coping methods that may be unacceptable in society (Gorski and Kelley, 2003). In addition, the family may not have been able to provide guidance or foster the development of social and occupational skills that allow the person to fully participate in society (Gorski and Kelley, 2003). This lack of skills and distorted personality functioning may cause addictive behaviors to occur, and these problems may also contribute to a more rapid progression of the addiction, make it difficult to recognize and seek treatment during the early stages of the addiction, and make it hard to benefit from treatment (Gorski and Kelley, 2003).

There are four goals in the primary treatment of dependency on alcohol and other drugs, as defined by Gorski and Kelley, 2003: recognition that chemical dependency is a bio/psycho/social disease; recognition of the need for life-long abstinence from all mind-altering drugs; development and use of an ongoing recovery program to maintain abstinence; diagnosis and treatment of other problems or conditions that can interfere with recovery.

Traditional treatment has taken one of two general approaches: The Medical Model which tries to help the patient meet the first three goals listed above; The Social/Behavioral Model which focuses on the fourth goal listed above, i.e., the diagnosis and treatment of other problems that can interfere with recovery (Gorski and Kelley, 2003).

The lack of a model that includes all of the components can lead to high relapse rates, especially in criminal justice populations: relapse prevention therapy is a model that uses an approach that works with all four components (Gorski and Kelley, 2003).

What Is Recovery?

A comprehensive model of chemical dependency treatment effectively combines the best of the medical and social/behavioral treatment models, and is based on the idea that recovery is a process that takes place over time, in specific stages, with each stage having tasks that need to be accomplished and skills to be developed (Gorski and Kelley, 2003). If a recovering person is unaware of this progression, unable to accomplish the tasks and gain the skills, or lacks adequate treatment, he or she will relapse (Gorski and Kelley, 2003).

The following is a description of this comprehensive model, which is called the Developmental Model of Recovery (DMR) (Gorski and Kelley, 2003).

The Developmental Model of Recovery (Gorski and Kelley, 2003)

The DMR has been devised to help recovering people and treatment professionals identify appropriate recovery plans, set treatment goals, and measure progress (Gorski and Kelley, 2003). The DMR describes six stages or periods of recovery (Gorski and Kelley, 2003):

Transition Stage, which begins the first time a person experiences an alcohol or drug-related problem (Gorski and Kelley, 2003). As a person's addiction progresses, he or she tries a series of strategies designed to control use (Gorski and Kelley, 2003). This ends with recognition by the person that safe use of alcohol and/or drugs is no longer possible (Gorski and Kelley, 2003).

The struggle for control is a symptom of a fundamental conflict over personal identity (Gorski and Kelley, 2003). Alcoholics and drug addicts enter this phase of recovery believing they are normal drinkers and drug users capable of controlled use (Gorski and Kelley, 2003). As the progression of addiction causes more severe loss of control, they must face the fact that they are addictive users who are not capable of controlled use (Gorski and Kelley, 2003).

During the transition stage, chemically dependent people typically attempt to control their use or stop using (Gorski and Kelley, 2003). They are usually trying to prove to themselves and others that they can use safely, but this never works for very long (Gorski and Kelley, 2003). Controlled use is especially tough for people who are participating in criminal behavior, because the high level of alcohol and drug use among their peers makes their lifestyle and use seem normal (Gorski and Kelley, 2003).

The major cause of inability to abstain during the transition stage is the belief that there is a way to control use (Gorski and Kelley, 2003).

Stabilization Period: during the stabilization period, chemically dependent people experience physical withdrawal and other medical problems, learn how to break the psychological conditioning causing the urge to use, stabilize the crisis that motivated them to seek treatment, and learn to identify and manage symptoms of brain dysfunction. This prepares them for the long-term processes of rehabilitation (Gorski and Kelley, 2003).

Traditional treatment often underestimates the need for management of these issues, focusing instead on detoxification (Gorski and Kelley, 2003). Patients find themselves unable to cope with the stress and pressure of the symptoms of brain dysfunction and physical cravings that follow detoxification (Gorski and Kelley, 2003). Many have difficulty gaining much from treatment and feel they are incapable of recovery (Gorski and Kelley, 2003). The lack of a supportive environment for recovery that many criminal offenders experience adds stress and undermines their attempts to stabilize these symptoms (Gorski and Kelley, 2003). They often use alcohol and drugs to relieve such distress, and it takes between 6 weeks and 6 months for a patient to learn to master these symptoms with the correct therapy (Gorski and Kelley, 2003).

The major cause of inability to abstain during the stabilization period is the lack of stabilization management skills (Gorski and Kelley, 2003).

Early Recovery Period: early recovery is marked by the need to establish a chemical-free lifestyle (Gorski and Kelley, 2003). The recovering person must learn about the addiction and recovery process (Gorski and Kelley, 2003). He or she must separate from friends who use and build relationships that support long-term recovery (Gorski and Kelley, 2003). This may be a very difficult time for criminal justice patients who have never associated with people with sobriety-based lifestyles (Gorski and Kelley, 2003).

They also need to learn how to develop recovery-based values, thinking, feelings, and behaviors to replace the ones formed in addiction (Gorski and Kelley, 2003). The thoughts, feelings, and behaviors developed by people with criminal lifestyles complicate and hinder their involvement in appropriate support programs during this period (Gorski and Kelley, 2003). Major intervention to teach the patient these skills is necessary if he or she is to succeed, and this period can be expected to last for 1-2 years (Gorski and Kelley, 2003).

The primary cause of relapse during the early recovery period is the lack of effective social and recovery skills necessary to build a sobriety-based lifestyle (Gorski and Kelley, 2003).

Middle Recovery Period: middle recovery is marked by the development of a balanced lifestyle: during this stage, recovering people learn to repair past damage done to their lives (Gorski and Kelley, 2003).

The recovery program is modified to allow time to re-establish relationships with family, set new vocational goals, and expand social outlets (Gorski and Kelley, 2003). The patient moves out of the protected environment of a recovery support group to assume a more mainstream and normal lifestyle (Gorski and Kelley, 2003). This is a time of stress as a person begins applying basic recovery skills to real-life problems (Gorski and Kelley, 2003).

The major cause of relapse during the middle recovery period is the stress of real-life problems (Gorski and Kelley, 2003).

Late recovery period: during late recovery, a person makes changes in ongoing personality issues that have continued to interfere with life satisfaction (Gorski and Kelley, 2003). In traditional psychotherapy, this is referred to as self-actualization (Gorski and Kelley, 2003). It is a process of examining the values and goals that one has adopted from family, peers, and culture (Gorski and Kelley, 2003). Conscious choices are then made about keeping these values or discarding them and forming new ones. In normal growth and development, this process occurs in a person's mid-twenties (Gorski and Kelley, 2003). Among people in recovery, it does not usually occur until between 3-5 years into the recovery process, no matter when recovery begins (Gorski and Kelley, 2003).

For criminal offenders, this is the time when they learn to change self-defeating behaviors that may trigger a return to alcohol or drug use (Gorski and Kelley, 2003). These self-defeating behaviors often come from psychological issues starting in childhood, such as childhood physical or sexual abuse, abandonment, or cultural barriers to personal growth (Gorski and Kelley, 2003).

The major cause of relapse during the late recovery period is either the inability to cope with the stress of unresolved childhood issues or an evasion of the need to develop a functional personality style (Gorski and Kelley, 2003).

Maintenance Stage: the maintenance stage is the life-long process of continued growth and development, coping with adult life transitions, managing routine life problems, and guarding against relapse (Gorski and Kelley, 2003). The physiology of addiction lasts for the rest of a person's life (Gorski and Kelley, 2003). Any use of alcohol or drugs will reactivate physiological, psychological, and social progression of the disease (Gorski and Kelley, 2003).

The major causes of relapse during the maintenance stage are the failure to maintain a recovery program and encountering major life transitions (Gorski and Kelley, 2003).

Sticking Points in Recovery (Gorski and Kelley, 2003)

Although some patients progress through the stages of recovery without complications, most chemically dependent people do not (Gorski and Kelley, 2003). They typically get stuck somewhere (Gorski and Kelley, 2003). A "stuck point" can occur during any period of recovery, and usually it is caused either by lack of skills or lack of confidence in one's ability to complete a recovery task (Gorski and Kelley, 2003). Other problems occur when the recovering person encounters a problem (physical, psychological, or social) that interferes with his or her ability to use recovery supports (Gorski and Kelley, 2003).

When recovering people encounter stuck points, they either recognize they have a problem and take action, or they lapse into the familiar coping skill of denial that a problem exists (Gorski and Kelley, 2003). Without specific relapse prevention skills to identify and interrupt denial, stress begins to build (Gorski and Kelley, 2003). Eventually, the stress will cause the patient to cope less and less well: this will result in relapse (Gorski and Kelley, 2003).

The Developmental Model of Recovery Compared With Traditional Models (Gorski and Kelley, 2003)

Traditional models of treatment are based on the idea that once a person is detoxified, he or she can fully participate in the treatment process (Gorski and Kelley, 2003). Although this is true for many patients in the early stages of addiction, who have had functional lives before their addiction progressed, it is not true for most of the criminal justice population (Gorski and Kelley, 2003). In addition, most traditional programs have a program format that is applied to all people regardless of their education, personality, or social skills: patients whose needs fit within the program usually do well, but those whose needs do not fit, such as criminal justice patients, generally do not do well (Gorski and Kelley, 2003).

The DMR recognizes that there are abstinence-based symptoms of addiction that persist well into the recovery process (Gorski and Kelley, 2003). These symptoms are physical and psychological effects of the disease of chemical dependency (Gorski and Kelley, 2003). In the DMR, these symptoms must be stabilized and the patient must be taught how to manage them before general rehabilitation can take place (Gorski and Kelley, 2003). This model identifies the specific symptoms that a patient needs to overcome (Gorski and Kelley, 2003).

This model also contains methods and techniques that recognize the learning needs, psychological problems, and social skills of the patient (Gorski and Kelley, 2003).

Post-Acute Withdrawal (Gorski and Kelley, 2003)

Some of the symptoms of withdrawal from alcohol or drugs are the result of the toxic effects of these chemicals on the brain (Gorski and Kelley, 2003). These symptoms are called Post Acute Withdrawal (PAW), which is more severe for some patients than it is for others (Gorski and Kelley, 2003). Other factors cause stress that aggravates PAW (Gorski and Kelley, 2003). Below is a list of conditions affecting the criminal justice population that tend to worsen the damage and aggravate PAW (Gorski and Kelley, 2003).

Physical conditions that worsen PAW through increased brain damage or disrupted brain function: Combined use of alcohol and drugs or different types of drugs; Regular use of alcohol or drugs before age 15 or abusive use for a period of more than 15 years; History of head trauma (from car accidents, fights, falling, etc.); Parental use of alcohol or drugs during pregnancy; Personal or family history of metabolic disease such as diabetes or hypoglycemia; Personal history of malnutrition, usually due to chemical dependence; Physical illness or chronic pain (Gorski and Kelley, 2003).

Psychological and social conditions that worsen PAW include: Childhood or adult history of psychological trauma (participant in or victim of sexual or physical violence); Mental illness or severe personality disorder; High stress lifestyle or personality; High stress social environment (Gorski and Kelley, 2003).

Addictive Preoccupation (Gorski and Kelley, 2003)

The other major area of abstinence-based symptoms is addictive preoccupation (Gorski and Kelley, 2003). This consists of the obsessive thought patterns, compulsive behaviors, and physical cravings caused or aggravated by the addiction (Gorski and Kelley, 2003). These behaviors become programmed into the patient's psychological processes by the addiction (Gorski and Kelley, 2003). They are automatic and can cause the recovering patient to return to use unless he or she has specific training to identify and interrupt them (Gorski and Kelley, 2003).

Addictive preoccupations are activated by high-risk situations and stress: because of the environment surrounding most criminal justice patients, they often experience high-risk situations and stress (Gorski and Kelley, 2003). These situations and stresses can include: Exposure to alcohol or drugs or associated paraphernalia; Exposure to places where alcohol or drugs are used; Exposure to people with whom the patient has used in the past or people the patient knows who are actively using; Lack of a stable home environment; Lack of a stable social environment; Lack of stable employment (Gorski and Kelley, 2003).

Traditional treatment focuses on either detoxification alone or detoxification with movement into a rehabilitation program aimed at changing the patient's lifestyle (Gorski and Kelley, 2003). Programs are similar for all patients, and many programs omit teaching the specific stabilization skills that are necessary before lifestyle rehabilitation can take place (Gorski and Kelley, 2003).

The DMR first stabilizes patients so that they can take advantage of lifestyle rehabilitation (Gorski and Kelley, 2003). It then places the patient into a group that contains patients in similar stages of recovery and works on tasks and skills for that stage of recovery (Gorski and Kelley, 2003). Specific skills are taught to identify and manage relapse warning signs (Gorski and Kelley, 2003).

What Is Relapse? (Gorski and Kelley, 2003)

Relapse is not an isolated event, rather, it is a process of becoming unable to cope with life in sobriety (Gorski and Kelley, 2003). The process may lead to renewed alcohol or drug use, physical or emotional collapse, or suicide (Gorski and Kelley, 2003). The relapse process is marked by predictable and identifiable warning signs that begin long before a return to use or collapse occurs (Gorski and Kelley, 2003). Relapse prevention therapy teaches people to recognize and manage these warning signs so that they can interrupt the progression early and return to the process of recovery (Gorski and Kelley, 2003).

Studies of life-long patterns of recovery and relapse indicate that not all patients relapse: approximately one third achieve permanent abstinence from their first serious attempt at recovery (Gorski and Kelley, 2003). Another third have a period of brief relapse episodes but eventually achieve long-term abstinence (Gorski and Kelley, 2003). An additional one third have chronic relapses that result in eventual death from chemical addiction (Gorski and Kelley, 2003).

These statistics are consistent with the life-long recovery rates of any chronic lifestyle-related illness (Gorski and Kelley, 2003). About half of all relapse-prone people eventually achieve permanent abstinence (Gorski and Kelley, 2003). Many others lead healthier, more stable lives despite periodic relapse episodes (Gorski and Kelley, 2003).

Classification of Recovery/Relapse History (Gorski and Kelley, 2003).

For the purpose of relapse prevention therapy, chemically dependent people can be categorized according to their recovery/relapse history (Gorski and Kelley, 2003). These categories are as follows: Recovery-Prone; Briefly Relapse-Prone and Chronically Relapse-Prone (Gorski and Kelley, 2003).

These categories correspond with the outcome categories of continuous abstinence, brief relapse, and chronic relapse described above (Gorski and Kelley, 2003). Relapse-prone individuals can be further divided into three distinct subgroups (Gorski and Kelley, 2003).

Transition patients fail to recognize or accept that they are suffering from chemical addiction in spite of problems from their use (Gorski and Kelley, 2003). This failure is usually due to the chemical disruption of the patient's ability to accurately perceive reality, or to mistaken beliefs (Gorski and Kelley, 2003).

Unstabilized relapse-prone patients have not been taught to identify the abstinence-based symptoms of PAW and addictive preoccupation (Gorski and Kelley, 2003). Treatment fails to provide these patients with the skills necessary to interrupt their disease progression and stop using alcohol and drugs (Gorski and Kelley, 2003). As a result, they are unable to adhere to a recovery program requiring abstinence, treatment, and lifestyle change (Gorski and Kelley, 2003).

Stabilized relapse-prone patients recognize that they are chemically dependent, need to maintain abstinence to recover, and need to maintain an ongoing recovery program to stay abstinent (Gorski and Kelley, 2003). They usually attend Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or another 12-step program in addition to receiving ongoing professional treatment (Gorski and Kelley, 2003). They also make protracted efforts at psychological and physical rehabilitation and recommended lifestyle changes during abstinence (Gorski and Kelley, 2003). However, despite their efforts, these people develop symptoms of dysfunction that eventually lead them back to alcohol or drug use (Gorski and Kelley, 2003).

Many counselors mistakenly believe that most relapse-prone patients are not motivated to recover (Gorski and Kelley, 2003). Clinical experience has not supported this belief: more than 80% of relapse-prone patients admitted to the relapse prevention program at Father Martin's Ashley in Havre de Grace, Maryland, had a history of both recognition of their chemical addiction and motivation to follow aftercare recommendations at time of discharge (Gorski and Kelley, 2003). In spite of this, they were unable to maintain abstinence and sought treatment in a specialized relapse prevention program that he or she became aware of during this exercise (Gorski and Kelley, 2003).

Relapse Prevention Treatment (Gorski and Kelley, 2003).

What Is Relapse Prevention Treatment? (Gorski and Kelley, 2003).

Relapse prevention is a systematic method of teaching recovering patients to recognize and manage relapse warning signs (Gorski and Kelley, 2003). Relapse prevention becomes the primary focus for patients who are unable to maintain abstinence from alcohol or drugs despite primary treatment (Gorski and Kelley, 2003).

Recovery is defined as abstinence plus a full return to bio/psycho/social functioning: as previously noted, relapse is defined as the process of becoming dysfunctional in recovery, which leads to a return to chemical use, physical or emotional collapse, or suicide (Gorski and Kelley, 2003). Relapse episodes are usually preceded by a series of observable warning signs: typically, relapse progresses from bio/psycho/social stability through a period of progressively increasing distress that leads to physical or emotional collapse (Gorski and Kelley, 2003). The symptoms intensify unless the individual turns to the use of alcohol or drugs for relief (Gorski and Kelley, 2003).

To understand the progression of warning signs, it is important to look at the dynamic interaction between the recovery and relapse processes (Gorski and Kelley, 2003). Recovery and relapse can be described as related processes that unfold in six stages: Abstaining from alcohol and other drugs; Separating from people, places, and things that promote the use of alcohol or drugs, and establishing a social network that supports recovery; Stopping self-defeating behaviors that prevent awareness of painful feelings and irrational thoughts; Learning how to manage feelings and emotions responsibly without resorting to compulsive behavior or the use of alcohol or drugs; Learning to change addictive thinking patterns that create painful feelings and self-defeating behaviors; Identifying and changing the mistaken core beliefs about oneself, others, and the world that promote irrational thinking (Gorski and Kelley, 2003).

When people who have had a stable recovery and have done well begin to relapse, they simply reverse this process (Gorski and Kelley, 2003). In other words, they: Have a mistaken belief that causes irrational thoughts; Begin to return to addictive thinking patterns that cause painful feelings; Engage in compulsive, self-defeating behaviors as a way to avoid the feelings; Seek out situations involving people who use alcohol and drugs; Find themselves in more pain, thinking less rationally, and behaving less responsibly; Find themselves in a situation in which drug or alcohol use seems like a logical escape from their pain, and they use alcohol or drugs (Gorski and Kelley, 2003).

A number of basic principles and procedures underlie the CENAPS Model of Relapse Prevention Therapy (Gorski and Kelley, 2003). Each principle forms the basis of specific relapse prevention therapy procedures (Gorski and Kelley, 2003). Counselors can use the following principles and procedures to develop appropriate treatment plans for relapse-prone patients (Gorski and Kelley, 2003). Following a description of each principle is the relapse prevention procedure for that principle (Gorski and Kelley, 2003).

Principle 1 (Gorski and Kelley, 2003). Self-Regulation: The risk of relapse will decrease as a patient's capacity to self-regulate thinking, feeling, memory, judgment, and behavior increases (Gorski and Kelley, 2003).

Relapse Prevention Procedure 1: Stabilization (Gorski and Kelley, 2003).

An initial treatment plan is established that allows relapse-prone individuals to stabilize physically, psychologically, and socially (Gorski and Kelley, 2003). The level of stabilization is measured by the ability to perform the basic activities of daily living, because the symptoms of withdrawal are stress-sensitive, it is important to evaluate the patient's level of stability under both high and low stress (Gorski and Kelley, 2003). Many people who appear stable in a low-stress environment become unstable when placed in a more stressful environment (Gorski and Kelley, 2003).

The stabilization process often includes: Detoxification from alcohol and other drugs; Solving the immediate crises that threaten sobriety; Learning skills to identify and manage Post Acute Withdrawal and Addictive Preoccupation; Establishing a daily structure that includes proper diet, exercise, stress management, and regular contact with treatment personnel and self-help groups (Gorski and Kelley, 2003).

As the risk of using alcohol or drugs is highest during the stabilization period, steps must be taken to prevent use during this time (Gorski and Kelley, 2003). The patient needs to be in a drug-free environment (Gorski and Kelley, 2003). Any irrational thoughts (thoughts that don't make sense to a healthy person) that are creating immediate justification for relapse need to be identified and discussed (Gorski and Kelley, 2003). The patient should then be helped to remember the consequences of past chemical use and to develop new coping strategies (Gorski and Kelley, 2003).

An early relapse intervention plan can be developed by the counselor and patient to decide what action to take if the patient begins to use alcohol or drugs: this early intervention plan motivates the patient to stay sober and provides a safety net should chemical use occur (Gorski and Kelley, 2003).

Principle 2 (Gorski and Kelley, 2003). Integration: The risk of relapse will decrease as the level of conscious understanding and acceptance of situations and events that have led to past relapses increases (Gorski and Kelley, 2003).

Relapse Prevention Procedure 2: Self-Assessment

Self-assessment first involves a detailed reconstruction of the presenting problems (problems that caused the patient to seek treatment) and the alcohol and drug use history (Gorski and Kelley, 2003). A careful exploration of the presenting problems identifies critical issues that can trigger relapse (Gorski and Kelley, 2003). This allows the counselor to design intervention plans that help to solve crises that can be used for relapse justification in the early treatment stages (Gorski and Kelley, 2003). The next step is a reconstruction of the recovery and relapse history: this helps identify past causes of relapse (Gorski and Kelley, 2003).

In reconstructing the recovery/relapse history, it is important to identify the recovery tasks that were completed or ignored, and to find the sequence of warning signs that led back to drug or alcohol use (Gorski and Kelley, 2003). The assessment is most effective if the counselor reconstructs the relapse history using exercises (done as homework assignments), such as making a list of all relapse episodes and identifying the problems that led to relapse (Gorski and Kelley, 2003). These assignments should be reviewed in group and individual sessions (Gorski and Kelley, 2003).

Principle 3 (Gorski and Kelley, 2003). Understanding: The risk of relapse will decrease as the understanding of the general factors that cause relapse increases (Gorski and Kelley, 2003).

Relapse Prevention Procedure 3: Relapse Education (Gorski and Kelley, 2003).

Relapsers need accurate information about what causes relapse and what can be done to prevent it (Gorski and Kelley, 2003). This is typically provided in structured relapse education sessions and reading assignments, which provide specific information about recovery, relapse, and relapse prevention planning methods (Gorski and Kelley, 2003). This information should include, but not be limited to: A bio/psycho/social model of addictive disease; A DMR; Common Astuck points" in recovery; Complicating factors in relapse; Warning sign identification; Relapse warning sign management strategies; Effective recovery planning (Gorski and Kelley, 2003).

The recommended format for a relapse education session is as follows: Introduction and pretest (15 minutes); Educational presentation, lecture, film, or videotape (30 minutes); Educational exercise conducted in dyads or small groups (15 minutes); Large group discussion (15 minutes); Post-test session and review of correct answers (15 minutes) (Gorski and Kelley, 2003).

It is important to test patients to determine their retention and understanding of the material (Gorski and Kelley, 2003). Many relapsers have severe memory problems associated with Post Acute Withdrawal that prevent them from comprehending or remembering educational information (Gorski and Kelley, 2003).

Principle 4 (Gorski and Kelley, 2003). Self-Knowledge: The risk of relapse will decrease as the patient's ability to recognize personal relapse warning signs increases (Gorski and Kelley, 2003).

Relapse Prevention Procedure 4: Warning Sign Identification (Gorski and Kelley, 2003).

Warning sign identification is the process of teaching patients to identify the sequence of problems that has led from stable recovery to alcohol and drug use in the past and then recognizing how those steps could cause relapse in the future (Gorski and Kelley, 2003). The process of developing a personal relapse warning sign list is (1) reviewing warning signs, (2) making an initial warning sign list, (3) analyzing warning signs, and (4) making a final warning sign list (Gorski and Kelley, 2003).

The patient develops his or her own individualized warning sign list by thinking of irrational thoughts, unmanageable feelings, and self-defeating behaviors (Gorski and Kelley, 2003). Most final warning sign lists identify two different types of warning signs: those related to core psychological issues (problems from childhood) and those related to core addictive issues (problems from the addiction) (Gorski and Kelley, 2003). Warning signs related to core psychological issues create pain and dysfunction, but they do not directly cause a person to relapse into chemical use (Gorski and Kelley, 2003). When patterns of addictive thinking that justify relapse are reactivated, a return to using alcohol and drugs occurs (Gorski and Kelley, 2003).

Principle 5 (Gorski and Kelley, 2003). Coping Skills: The risk of relapse will decrease as the ability to manage relapse warning signs increases (Gorski and Kelley, 2003).

Relapse Prevention Procedure 5: Warning Sign Management (Gorski and Kelley, 2003)

This involves teaching relapse-prone patients how to manage or cope with their warning signs as they occur: the better they are at coping with warning signs, the better their ability will be to stay in recovery (Gorski and Kelley, 2003).

Warning sign management should focus on three distinct levels (Gorski and Kelley, 2003). The first is the situational-behavioral level, where patients are taught to avoid situations that trigger warning signs (Gorski and Kelley, 2003). At this level, they are taught to modify their behavioral responses should these situations arise (Gorski and Kelley, 2003). The second level is the cognitive affective (thoughts and feelings) level, where patients are taught to challenge their irrational thoughts and deal with their unmanageable feelings that emerge when a warning sign is activated (Gorski and Kelley, 2003). The third level is the core issue level, where patients are taught to identify the core addictive and psychological issues that initially create the warning signs (Gorski and Kelley, 2003).

Principle 6 (Gorski and Kelley, 2003). Change: The risk of relapse will decrease as the relationship between relapse warning signs and recovery program recommendations increases (Gorski and Kelley, 2003).

Relapse Prevention Procedure 6: Recovery Planning (Gorski and Kelley, 2003).

Recovery planning involves the development of a schedule of recovery activities that will help patients recognize and manage warning signs as they develop in sobriety (Gorski and Kelley, 2003). This is done by reviewing each warning sign on the final warning sign list and ensuring that there is a scheduled recovery activity focused on each sign (Gorski and Kelley, 2003). Each critical warning sign needs to be linked to a specific recovery activity (Gorski and Kelley, 2003).

Principle 7 (Gorski and Kelley, 2003). Awareness: The risk of relapse will decrease as the use of daily inventory techniques designed to identify relapse warning signs increases (Gorski and Kelley, 2003).

Relapse Prevention Procedure 7: Inventory Training (Gorski and Kelley, 2003).

Inventory training involves teaching relapse-prone patients to complete daily inventories (Gorski and Kelley, 2003). These inventories monitor compliance with the recovery program and check for the emergence of relapse warning signs (Gorski and Kelley, 2003). A daily recovery plan sheet is used to plan the day, and an evening inventory sheet is used to review progress and problems that occurred during that day (Gorski and Kelley, 2003).

A typical morning inventory asks the patient to identify three primary goals for that day, create a to-do list, then schedule time for completion of each task on the to-do list on a daily calendar (Gorski and Kelley, 2003). During the evening review inventory, the patient should review his or her warning sign list and recovery plan to determine whether he or she completed the required activities and experienced any relapse warning signs (Gorski and Kelley, 2003).

Whenever possible, these inventories should be reviewed by someone who knows the patient and who can assist him or her in looking for emerging patterns of problems that could cause relapse (Gorski and Kelley, 2003).

Principle 8 (Gorski and Kelley, 2003). Significant Others: The risk of relapse will decrease as the responsible involvement of significant others in recovery and in relapse prevention planning increases (Gorski and Kelley, 2003).

Relapse Prevention Procedure 8: Involvement of Others (Gorski and Kelley, 2003).

Relapse-prone individuals cannot recover alone. They need the help of others. Family members, 12-step program sponsors, counselors, and peers are just a few of the many recovery resources available (Gorski and Kelley, 2003). A counselor should ensure that others are involved in the recovery process whenever possible (Gorski and Kelley, 2003). The more psychologically and emotionally healthy the significant others are, the more likely they are to help the relapse-prone patient remain abstinent (Gorski and Kelley, 2003). The more directly the significant others are involved in the relapse prevention planning process, the more likely they are to become productively involved in supporting positive efforts at recovery and intervening on relapse warning signs or initial chemical use (Gorski and Kelley, 2003).

Principle 9 (Gorski and Kelley, 2003). Maintenance: The risk of relapse decreases if the relapse prevention plan is regularly updated during the first 3 years of sobriety (Gorski and Kelley, 2003).

Relapse Prevention Procedure 9: Relapse Prevention Plan Updating (Gorski and Kelley, 2003).

The patient's relapse prevention plan needs to be updated on a monthly basis for the first 3 months, quarterly for the remainder of the first year, and twice a year for the next 2 years (Gorski and Kelley, 2003). Once a person has maintained 3 years of uninterrupted sobriety, the relapse prevention plan should be updated on a yearly basis (Gorski and Kelley, 2003).

Nearly two thirds of all relapses occur during the first 6 months of recovery (Gorski and Kelley, 2003). Less than one quarter of the variables that actually cause relapse can be predicted during the initial treatment phase (Gorski and Kelley, 2003). As a result, ongoing outpatient treatment is necessary for effective relapse prevention (Gorski and Kelley, 2003). Even the most effective short-term inpatient or primary outpatient programs will fail to interrupt long-term relapse cycles without the ongoing reinforcement of some type of outpatient therapy (Gorski and Kelley, 2003).

A relapse prevention plan update session involves the following: A review of the original assessment, warning sign list, management strategies, and recovery plan; An update of the assessment by adding documents that are significant to progress or problems since the previous update; A revision of the relapse warning sign list to incorporate new warning signs that have developed since the previous update; The development of management strategies for the newly identified warning signs; A revision of the recovery program to add recovery activities to address the new warning signs and to eliminate activities that are no longer needed (Gorski and Kelley, 2003).

Basic Counseling Skills (Gorski and Kelley, 2003).

This section discusses some basic counseling skills that can be used in individual and group counseling (Gorski and Kelley, 2003). It also explains some of the concepts and terms used in relapse prevention counseling that you will need to help patients with the workbook (Gorski and Kelley, 2003).

Helping Traits (Gorski and Kelley, 2003).

People who are effective at counseling have developed eight behaviors that they use during counseling sessions (Gorski and Kelley, 2003). It is important to develop these traits if you are to improve your ability to help others (Gorski and Kelley, 2003). The counselor is a role model (someone whom patients tend to imitate), and therefore, you want to model behaviors that will be helpful to patients' recovery (Gorski and Kelley, 2003). The following are some of these traits:

Empathy, which is the ability to understand how another person sees and interprets an experience (Gorski and Kelley, 2003). It is different from sympathy (feeling sorry for someone): when you are empathetic, you can look at and understand a situation from another person's perspective (Gorski and Kelley, 2003). It does not mean you have to agree with that person (Gorski and Kelley, 2003).

Genuineness, which is the ability to be fully yourself and express yourself to others (Gorski and Kelley, 2003). It is the lack of phoniness, faking, and defensiveness (Gorski and Kelley, 2003). When you are genuine, the way you act on the outside matches your thoughts and feelings on the inside (Gorski and Kelley, 2003).

Respect, which is the ability to let another person know, through your words and actions, that you believe that he or she has the ability to make it in life, the right to make his or her own decisions, and the ability to learn from the outcome of those decisions (Gorski and Kelley, 2003).

Self-Disclosure, which is the ability to disclose information about yourself, the ways you think and feel, the things you believe, in order to help other people (Gorski and Kelley, 2003).

Warmth, which is the ability to show another person you care about him or her (Gorski and Kelley, 2003). Behaviors that show warmth include touching someone, making eye contact, smiling, and having a caring, sincere tone of voice (Gorski and Kelley, 2003).

Immediacy, which is the ability to focus on the "here and now" relationship with another person (Gorski and Kelley, 2003). You can express immediacy by saying things like: "Right now I am feeling ____." "When you said that, I began to think ____." "As you were speaking, I sensed that you felt ____." (Gorski and Kelley, 2003)

Concreteness, which is the ability to identify specific problems and the steps necessary to correct them (Gorski and Kelley, 2003). When a problem, situation, behavior, or set of actions is defined in concrete terms, you could draw a picture or make a movie about it if you were able (Gorski and Kelley, 2003).

Confrontation, which is the act of honestly telling another person your perception of what is going on without putting them down (Gorski and Kelley, 2003). Confronting someone can include: Giving an honest evaluation of the person's strengths and weaknesses; Saying what you believe the person is thinking and feeling; Stating how you see the person acting; Telling the person what you believe will happen because of their actions (Gorski and Kelley, 2003).

Active Listening (Gorski and Kelley, 2003).

When a patient is talking about a problem or presenting an assignment, it is important to listen actively (Gorski and Kelley, 2003). Active listening is a basic counseling skill that helps you clarify for yourself and the patient what is really going on (Gorski and Kelley, 2003). Patients in recovery are not always clear in their thinking (Gorski and Kelley, 2003). This lack of clarity can confuse them and those around them; active listening will help them clarify their thinking (Gorski and Kelley, 2003).

Active thinking consists of several skills, which include the following:

Clear listening (Gorski and Kelley, 2003). When you are listening to a patient, it is important to just listen (Gorski and Kelley, 2003). The most common problem for new counselors is that they think while they listen (Gorski and Kelley, 2003). If you are thinking about what you are going to say, you will not accurately hear what the person is saying (Gorski and Kelley, 2003). It is important that you listen without judging what the patient is saying and without immediately trying to correct his or her thoughts (Gorski and Kelley, 2003).

Reflecting (Gorski and Kelley, 2003). When someone talks to you, reflecting is summarizing and repeating that person's thoughts and feelings in a simple, clear manner (Gorski and Kelley, 2003). Reflecting helps clarify the issues for both of you (Gorski and Kelley, 2003). If you misunderstand the patient, he or she can correct you (Gorski and Kelley, 2003). When you repeat thoughts and feelings back to the patient, use statements instead of questions (Gorski and Kelley, 2003).

Example: Patient -- "I try and try to stay straight but everything goes wrong and I end up using again" (Gorski and Kelley, 2003).

Counselor: "You seem to feel hopeless about recovering" (Gorski and Kelley, 2003). Reflecting gives a patient the sense that you are really listening (Gorski and Kelley, 2003). He or she will tend to open up more and talk about problems he or she hasn't talked about before (Gorski and Kelley, 2003).

Asking-open ended questions (Gorski and Kelley, 2003). Do not ask questions that can be answered with a "yes" or a "no" (Gorski and Kelley, 2003). Instead, ask questions that require patients to explore the reasons they think, feel, and act the way they do (Gorski and Kelley, 2003).

Example: "What happens when you try to recover?" "What do you do when you feel hopeless?" (Gorski and Kelley, 2003).

Not asking "Why?" (Gorski and Kelley, 2003). Most new counselors make the mistake of asking "Why?" (Gorski and Kelley, 2003). The patient does not know why, or else he or she would have changed (Gorski and Kelley, 2003). If you ask "Why?" The patient will give you an excuse (Gorski and Kelley, 2003). By asking "What?" you are getting the patient to focus on what he or she has done that can be changed (Gorski and Kelley, 2003).

Using effective body language (Gorski and Kelley, 2003). How you physically position yourself tells a patient a lot about how you feel about him or her (Gorski and Kelley, 2003). When you are working with patients, it is best to sit with your legs and arms uncrossed, to lean forward and to make eye contact (Gorski and Kelley, 2003). This body position shows that you are interested in what the patient has to say and that you are paying attention (Gorski and Kelley, 2003).

Watching for nonverbal cues (Gorski and Kelley, 2003). When you are working with a patient, listen and watch carefully (Gorski and Kelley, 2003). Does the person tense up, tap his or her foot, shift around, etc. (Gorski and Kelley, 2003)? When you see these cues, make the patient aware of them and let him or her know what this might mean the patient is feeling (Gorski and Kelley, 2003).

Basic Relapse Prevention Techniques (Gorski and Kelley, 2003).

There are a number of techniques that are used when doing relapse prevention counseling (Gorski and Kelley, 2003).

Centering (Gorski and Kelley, 2003).

When you begin a group or an individual session or when you want a patient to calm down and get in touch with thoughts and feelings, you can use a technique called centering (Gorski and Kelley, 2003). This is basically a relaxation technique, during which you should instruct the patient to do the following: Put both feet on the floor, sit up straight and close your eyes; Breathe in through your nose and out through your mouth; Breathe in deeply, hold it for a second, then breathe out; Do this again and feel your lungs fill with air, then empty; Slow your breathing to a steady rhythm; See if any thoughts are entering your mind; Ask yourself if you are feeling any body tensions; Open your eyes when you are ready (Gorski and Kelley, 2003).

Speak slowly as you give the instructions (Gorski and Kelley, 2003). This will help the patient calm down (Gorski and Kelley, 2003).

Sentence completion (Gorski and Kelley, 2003).

Sentence completion is a technique used to help patients identify thoughts that they have that may not be true (Gorski and Kelley, 2003). These thoughts are called mistaken beliefs (Gorski and Kelley, 2003). Many times when a patient is acting in a self-defeating way, it is a result of mistaken beliefs he or she has about the world and himself or herself (Gorski and Kelley, 2003). When a patient is behaving in a way that hurts himself or herself and others, it is because the patient believes that this is the only choice he or she has (Gorski and Kelley, 2003). Sentence completion is a way to help a patient identify and correct mistaken beliefs (Gorski and Kelley, 2003). You do this by doing the following (Gorski and Kelley, 2003).

Have the patient form a sentence stem: A sentence stem is the beginning of a sentence that has meaning for the patient, and you can form these stems based on topics the patient is talking about (Gorski and Kelley, 2003). Examples are: "I know my recovery is in trouble when..." "When I think about drugs, I..." "Right now, I am feeling..." (Gorski and Kelley, 2003).

Have the patient write down the sentence stem (Gorski and Kelley, 2003).

Have the patient repeat it out loud and end it differently six to eight times or until he or she cannot think of new endings (Gorski and Kelley, 2003).

Have the other group members write down the endings. If you are in an individual session, do this yourself (Gorski and Kelley, 2003).

Have the group members read the endings back to the patient as they write them down, and have them use the following form: A (patient's name), I heard you say (sentence stem)(first ending) (Gorski and Kelley, 2003). Repeat the exercise until all the endings have been read (Gorski and Kelley, 2003).

Look for a common theme in the endings: you may form a new sentence stem from the common theme and repeat the exercise, or stop here if the mistaken belief is identified (Gorski and Kelley, 2003).

Have the patient identify the mistaken belief if he or she can and write it down (Gorski and Kelley, 2003).

Sentence repetition (Gorski and Kelley, 2003).

Sentence repetition is a way for a patient to become conscious of mistaken beliefs and the thoughts, feelings, and actions they cause (Gorski and Kelley, 2003). Identify the mistaken belief and ask the patient to write it down (Gorski and Kelley, 2003).

Ask the patient to repeat it out loud, slowly (Gorski and Kelley, 2003).

After each repetition, ask the patient to take a deep breath, let it out, and report any thoughts, feelings, or urges that surfaced (Gorski and Kelley, 2003).

Have the patient write down these thoughts, feelings, and urges (Gorski and Kelley, 2003).

Ask the patient if he or she can remember who caused this mistaken belief or where it came from (Gorski and Kelley, 2003).

Ask the patient if the person could have been wrong (Gorski and Kelley, 2003).

Ask the patient if there are other ways to believe that could be true. You may have to ask the group to help (Gorski and Kelley, 2003).

Ask the patient to complete the following sentences (Gorski and Kelley, 2003):

If I continue to believe this, the best that can happen is..."; "The worst that can happen is..."; "The most likely to happen is..."; "If I change what I believe, the best that can happen is..."; "The worst that can happen is..."; "The most likely to happen is..." (Gorski and Kelley, 2003).

The probable outcomes can be discussed and a course of action decided by the group; the most important decision is to identify a rational thought that the patient can substitute when the mistaken belief occurs (Gorski and Kelley, 2003).

Group Counseling (Gorski and Kelley, 2003).

Group counseling has proved to be the most effective way of treating chemical dependency (Gorski and Kelley, 2003). This section explains how to do group counseling (Gorski and Kelley, 2003). Patients in chemical dependency treatment programs learn best in group counseling, where patients learn about themselves by interacting with others (Gorski and Kelley, 2003). They also come to understand that they are not alone in their problems (Gorski and Kelley, 2003). In addition, they learn social and communication skills that allow them to make better use of self-help programs such as Alcoholics Anonymous and Narcotics Anonymous (Gorski and Kelley, 2003).

How Is Group Work Different From Individual Counseling (Gorski and Kelley, 2003)?

Group counseling and individual counseling are both important tools for treating chemical dependency (Gorski and Kelley, 2003). Group counseling uses many of the same intervention strategies as individual counseling (Gorski and Kelley, 2003). There are, however, some important distinctions between the two modalities (Gorski and Kelley, 2003). A common mistake for beginning group counselors is to focus an entire group meeting on one patient, while the others in the group simply look on (Gorski and Kelley, 2003).

Group counseling is different from individual counseling in the following ways:

Group counseling focuses on the present; the here and now (Gorski and Kelley, 2003). In group counseling, patients do not delve into long accounts of personal history that preceded the problems of chemical dependency (Gorski and Kelley, 2003). Group counseling provides a forum to understand current behavior, to learn about chemical dependency, to discuss new ways of behaving, to learn new ways to solve problems, and to develop relapse prevention skills (Gorski and Kelley, 2003).

Group counseling makes use of the interactive process within the group (Gorski and Kelley, 2003). That is, the counselor focuses on how the group members act toward one another, communicate with one another, and how they behave in the group (Gorski and Kelley, 2003).

The counselor and group members offer individuals feedback about their behavior (Gorski and Kelley, 2003). In individual counseling patients simply disagree with their counselor (Gorski and Kelley, 2003). In group counseling the counselor's feedback is combined with positive peer feedback from the group members (Gorski and Kelley, 2003). This makes messages more powerful (Gorski and Kelley, 2003).

The group provides a place for the counselor to help individuals practice new skills such as problem solving, communication, and managing stress (Gorski and Kelley, 2003).

In group counseling, the counselor uses a peer group to influence individual patients and change behavior in a positive way (Gorski and Kelley, 2003).

Group Counseling Theory: Stages of Group Development (Gorski and Kelley, 2003).

When a group first begins, counselors and group members alike will feel very uncomfortable (Gorski and Kelley, 2003). The members may not know the counselor or one another (Gorski and Kelley, 2003). As people become familiar with the group, feelings and behavior begin to change (Gorski and Kelley, 2003). These changes follow predictable patterns (Gorski and Kelley, 2003). In fact, groups have a clear developmental life cycle, that is, a group goes through different stages (Gorski and Kelley, 2003). As the group leader gains experience, he or she learns to anticipate these changes and work with them (Gorski and Kelley, 2003).

There are many models for the stages of group development (Gorski and Kelley, 2003). The following is a composite of several models:

Stage 1 -- "Pre-affiliation

Stage 2 -- "Power and control

Stage 3 -- "Intimacy

Stage 4 -- "Differentiation

Stage 5 -- "Separation (Gorski and Kelley, 2003).

In the pre-affiliation stage, members feel uncomfortable, anxious, or fearful with the newness of the experience (Gorski and Kelley, 2003). In this stage, members look to the leader for direction (Gorski and Kelley, 2003). Initially, the group should be leader-focused, with the leader helping members adjust to the new experience (Gorski and Kelley, 2003).

Once group members are more comfortable, it is predictable that they will challenge the authority of the leader and will pursue power and control (Gorski and Kelley, 2003). It is important for the leader to remember that this is a normal style in the group's development, not unlike the challenges that face the parents of an adolescent (Gorski and Kelley, 2003). This phase may be uncomfortable, with group members expressing anger and frustration (Gorski and Kelley, 2003). The leader should be careful not to personalize these challenges to authority (Gorski and Kelley, 2003). The leader should be consistent, avoid fighting with the group, and allow the group to become more autonomous without sacrificing his or her position of authority (Gorski and Kelley, 2003).

In the next stage, some degree of intimacy is established (Gorski and Kelley, 2003). It is very important for the leader to move members to a common level of intimacy before allowing too much self-disclosure by the group members (Gorski and Kelley, 2003). The setting and type of the group will determine the overall level of intimacy (Gorski and Kelley, 2003). As members feel safer in the group, they can better engage in activities and take risks necessary for change (Gorski and Kelley, 2003). At this stage, the leader can give less direction, allowing the members to work together more spontaneously and more independently (Gorski and Kelley, 2003).

Differentiation is the stage at which members have a strong sense of identification with the group and feel trusting (Gorski and Kelley, 2003). This is the most productive stage of group development (Gorski and Kelley, 2003).

Finally, at the point of termination or separation, members experience a range of feelings and display a range of behaviors in anticipation of leaving the group (Gorski and Kelley, 2003). It is important to remember that chemically dependent people typically have experienced a lot of loss over their lifetimes (Gorski and Kelley, 2003). Many have lost family members and friends to violence and illness. They do not handle the ending of relationships well (Gorski and Kelley, 2003). Termination of the group or loss of a group member presents an important opportunity to deal with this problem (Gorski and Kelley, 2003). The leader should begin to prepare the group for ending well in advance and do so gradually (Gorski and Kelley, 2003). The leader can expect members to use denial or to regress; it is important to predict these behaviors and to identify them as they occur (Gorski and Kelley, 2003).

These stages of group development are very predictable (Gorski and Kelley, 2003). Virtually all groups go through them; however, depending upon the circumstances a group may regress to an earlier stage at any time (Gorski and Kelley, 2003). For example, if a group adds new members, the level of intimacy will decrease (Gorski and Kelley, 2003). The group may return to a stage of pre-affiliation (Gorski and Kelley, 2003). It is hard to predict how long a group will stay in a particular stage of development (Gorski and Kelley, 2003). The type of group (i.e., mandatory or voluntary), the setting (i.e. institution or community), and other factors can all influence the process (Gorski and Kelley, 2003). With experience, the group leader develops the skills to promote the group developmental process or alter (Gorski and Kelley, 2003).

Communication in Groups: Content and Interactive Process (Gorski and Kelley, 2003).

The terms "content" and "interactive process" refer to the patterns of communication among group members (Gorski and Kelley, 2003). "Content" refers to the substance of a communication (Gorski and Kelley, 2003). The content is the subject matter, including issues, questions, or problems on which the group is focused (Gorski and Kelley, 2003). "Interactive process" refers to how members communicate and act with one another (Gorski and Kelley, 2003). The process includes not only the spoken words, but also the nonverbal messages expressed by tone of voice, posture, and facial expression (Gorski and Kelley, 2003). Process provides the "present focus" or "here and now" raw material for group treatment (Gorski and Kelley, 2003).

The content of a group meeting sometimes symbolizes the group process (Gorski and Kelley, 2003). In the same way a client might talk about "a friend who has a problem," group members may talk about prior events and issues that reflect current experiences (Gorski and Kelley, 2003). Often as group leaders, we get caught up in the content (Gorski and Kelley, 2003). We are very interested in the what, when, where, who, how, and why (Gorski and Kelley, 2003). In group counseling, this content has relevance in a way that can be different from its relevance in individual counseling (Gorski and Kelley, 2003).

The Counselor as Group Leader (Gorski and Kelley, 2003).

Many techniques used in group counseling are similar to those used in individual counseling (Gorski and Kelley, 2003). The general approach of the group leader, however, must work to create a group culture that focuses on the "here and now" behavior (Gorski and Kelley, 2003). An active and dynamic approach along with an empathic style are needed to do this (Gorski and Kelley, 2003).

The group leader's focus should:

encourage group and individual recovery teach members about chemical dependency, recovery, and relapse prevention build members' self-esteem (Gorski and Kelley, 2003).

The group leader's approach should:

be empathic instill hope model desired behaviors treat all members consistently, equally, and fairly be active and directive use appropriate interventions to keep the group moving (Gorski and Kelley, 2003).

The group leader should:

maintain control in a nonauthoritative way be firm but not punitive be assertive in setting limits provide appropriate rewards (activities, trips, etc.) to the group (Gorski and Kelley, 2003).

Planning for Group Work (Gorski and Kelley, 2003).

Logistics (Gorski and Kelley, 2003).

All logistical arrangements should be planned well in advance of beginning the group (Gorski and Kelley, 2003). In order for the preplanning to go smoothly, group counselors should seek the support of appropriate administrative and support staff (Gorski and Kelley, 2003). Establish the following before getting started (Gorski and Kelley, 2003).

Group Size (Gorski and Kelley, 2003).

Groups typically range in size from 6 to 12 people (Gorski and Kelley, 2003). The size should be determined by such factors as the type of group and the capacity of the patients (Gorski and Kelley, 2003). "Capacity" refers to the level of individual functioning (Gorski and Kelley, 2003). Can the patient concentrate, focus, and pay attention (Gorski and Kelley, 2003)? Some substance abusers, particularly those in the early stages of recovery, cannot make use of all their mental functions (Gorski and Kelley, 2003). Others may have mental/emotional problems that interfere with these abilities (Gorski and Kelley, 2003). Low-functioning individuals will need a smaller group (Gorski and Kelley, 2003). Educational groups can handle more members, whereas process oriented-groups should be smaller (Gorski and Kelley, 2003).

Time (Gorski and Kelley, 2003).

Time is an important boundary (Gorski and Kelley, 2003). The length of group sessions should be preplanned if the group is to be time limited (Gorski and Kelley, 2003). A schedule of sessions should be established that considers holidays and other commitments (Gorski and Kelley, 2003).

Sessions should be of equal length (Gorski and Kelley, 2003). The ideal length depends on the capacity of the patients, the setting, and the type of group (Gorski and Kelley, 2003). More functional patients can handle longer sessions than less functional or younger patients (Gorski and Kelley, 2003). The materials presented in this manual are intended for two-hour group sessions (Gorski and Kelley, 2003).

Once the time boundaries have been established, it is very important to begin and end group sessions on time (Gorski and Kelley, 2003).

Space (Gorski and Kelley, 2003).

The space chosen for group meetings will make a statement about the importance given to this activity (Gorski and Kelley, 2003). The space should be psychologically positive and provide a safe environment for the emotional risks that go with treatment (Gorski and Kelley, 2003). The space should be well lighted, well ventilated, and an appropriate size for the size of the group (Gorski and Kelley, 2003). A private location that is accessible, free from interruptions, and physically safe should be chosen (Gorski and Kelley, 2003).

Types of Groups (Gorski and Kelley, 2003).

Different types of groups serve different purposes (Gorski and Kelley, 2003). The following is a review of some options to help you decide what type of group is most practical and useful for the setting (Gorski and Kelley, 2003).

Mandatory or Voluntary Group (Gorski and Kelley, 2003)?

You might assume that voluntary groups are best, but research and practice indicate that both voluntary and mandatory groups have their advantages and disadvantages (Gorski and Kelley, 2003).

Mandatory groups ensure that members will attend (Gorski and Kelley, 2003). With regular attendance the group process can develop with little disruption (Gorski and Kelley, 2003). Unfortunately, mandatory requirements often increase hostility and resistance and intensify denial (Gorski and Kelley, 2003). No one likes to be told they must go to a counseling group, and few counselors like being confronted with such hostility, particularly by a group of eight or more people (Gorski and Kelley, 2003).

When the counselor is well prepared, the situation can be managed (Gorski and Kelley, 2003). Patients will attempt to engage you in battle (Gorski and Kelley, 2003). The best tactic is to avoid these battles (Gorski and Kelley, 2003). One way to do so is to join with the group by saying something like, "You have to be here and I have to be here. I understand and appreciate your anger but it is not my fault. How can we both make the best of things?" (Gorski and Kelley, 2003). Offering concrete rewards for cooperation may also help (Gorski and Kelley, 2003). Setting rules for attendance can eliminate overt resistance but seldom reduces passive resistance (Gorski and Kelley, 2003).

The disadvantages of the mandatory group become the advantages of the voluntary group (Gorski and Kelley, 2003). Members of voluntary groups identify with one another, denial is less potent, there is less hostility, and one can move on more quickly to group goals (Gorski and Kelley, 2003). However, the voluntary group does not have some major disadvantages (Gorski and Kelley, 2003). When participation is voluntary, members often find excuses to be absent when there is pressure on them to face problems (Gorski and Kelley, 2003). Without a "captive" audience, leaders find that it is hard to ensure member attendance and that it is difficult for the group process to evolve with absent members (Gorski and Kelley, 2003).