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The Addiction Counselor’s Desk Reference
- By Misc Author
- Published 11/16/2007
- Addiction Research
- Unrated
Two prevention models are currently used: (1) the traditional classification employed for decades by public health workers and (2) a more recent classification proposed by the Institute of Medicine.
THE TRADITIONAL CLASSIFICATION
This historical classification includes (1) primary prevention, (2) secondary prevention, and (3) tertiary prevention (Pransky, 1991).
PRIMARY PREVENTION Implemented before a person begins using drugs, the intent is to prevent drug use completely, or at least delay consumption.
Examples of primary prevention include educational seminars, reading materials, school instruction, marketing information, community awareness programs, help lines, changes in the laws and regulations to make drugs less easily available, and instruction in coping and life skills.
SECONDARY PREVENTION Implemented after a person has experimented with drugs, the objective is to discourage escalation into more frequent or habitual use.
Examples of secondary prevention include strengthening families, helping parents become aware of the signs and symptoms of substance abuse, medical staff intervention at first signs of drug use, harm reduction programs, and public education to increase awareness about caring for a drug-using person.
TERTIARY PREVENTION Implemented after drug use has become a problem, the goal is to help the addicted person recover, or minimally, to reduce the harm resulting from drug use and to keep the addiction from worsening.
Examples of tertiary prevention include educating the public about the long-term consequences of alcohol and drug addiction, home care programs for individuals who can no longer care for themselves because of damages incurred with heavy use, and educating addicted people about safe needle exchange techniques.
Additional Resources -- See more on prevention by visiting the web site of the Division on Prevention, Public Health Service Office of Public Health and Science. Available from http://phs.os.dhhs.gov/ophs.
See also Coombs, R. H. & Ziedonis, D. (Eds.). (1995). Handbook on drug abuse prevention: A comprehensive strategy to prevent the abuse of alcohol and other drugs. Needham Heights, MA: Allyn & Bacon.
An outstanding prevention resource is provided at http://p2001.health.org/Ms03/PAM1SLID2.htm.
Also see the www.DrugsAlcohol.info web site for useful information on drug prevention, levels of prevention, and a list of references: www.drugsprevention.net/drugs/printpage.asp?d=G3.
THE INSTITUTE OF MEDICINE CLASSIFICATION
The Institute of Medicine (1989) proposed a newmodel of prevention types. Based on Gordon’s (1987) operational classification of disease prevention, this new model has three parts—prevention, treatment, and maintenance. It subdivides the prevention category into three types: universal, selective, and indicated.
UNIVERSAL PREVENTION -- Focusing on large populations (e.g., national, local community, school, or neighborhoods), these efforts seek to prevent or delay illicit drug use. An example is creating a prevention program for all students at a given school or school district.
SELECTIVE PREVENTION -- The focus is on specific populations known to be at great risk for substance abuse, such as targeting children of drug users or poor school achievers.
INDICATED PREVENTION -- These interventions are directed at those who have already experimented with drugs or who exhibit other risk-related behaviors. Examples include such welldocumented programs as Project STAR and Adolescent Alcohol Prevention Trial.
Other examples can be reviewed at National Institute on Drug Abuse, Prevention Research (n.d.). Available from www.nida.nih.gov/DrugPages/Prevention.html.
Additional Resources -- For more information on the Institute of Medicine go to www.iom.edu. See a detailed list of indicated prevention programs.
Available from www.unf.edu/dept/fie/sdfs/program_inventory/list.html.
PREVENTION PRINCIPLES
Prevention programs typically focus on three elements: (1) The person (e.g., prior drug use, skills, physiological reactions, and perceptions), (2) the situation (e.g., peer influence, family influence, opportunity, and social norms), and (3) the environment (e.g., access, media impact, schools, and community policies, and financial factors).
The last two—situation and environment—have proven the most effective target areas for designing addiction prevention programs (McCrady & Epstein, 1999).
Categories of risk factors include the following:
• Community: Access to drugs and firearms, community laws, and norms favorable toward drug use, crime, media portrayals of violence, transition and mobility, low neighborhood attachment and community disorganization, and extreme economic deprivation
• Family: Family history of problembehaviors, family management problems, family conflict, favorable parental attitude, and involvement in problembehaviors
• School: Early and persistent antisocial behavior, academic failure beginning in late elementary school, and lack of commitment to school
• Individual/peer: Alienation and rebelliousness, friends who engage in the problem behavior; favorable attitude toward the problem behavior; early initiation of the problem behavior and constitutional factors (Hogan Gabrielsen, Luna, & Grothaus, 2003, pp. 16–17)
Some headway is being made in understanding what constitutes effective prevention message presentation and content. A meta-analysis of 120 school-based preventive interventions for 5th- through 12th-grade students indicated that interactive programs change drug knowledge, attitudes, and behaviors, whereas noninteractive programs change only knowledge.
Prevention research has addressed how to encourage program participation, why programs are more or less effective, and how prevention interventions can have positive and negative effects (Gorski, 1989).
For optimal success, program planners and implementers should include:
• Flexibility scheduling
• Reduction of initial time commitments; active involvement of both parents and peers
• Multiple positive rewards aligned to the target population, such as: free food coupons, refreshments, and child care (Spoth, Redmond, & Shin, 1998)
The multidisciplinary prevention research program (NIMH Prevention Research at www.drugabuse.gov/DrugPages/Prevention.html) of theNational Institute on Drug Abuse (NIDA) released a set of prevention principles that enumerate what has been learned through 20 years of research.
Here are a few examples:
• Prevention programs should target all forms of drug use, including tobacco, alcohol, marijuana, and inhalants.
• Prevention programs should include skills to resist drugs when offered, strengthen personal commitments against drug use, and increase social competency.
• Prevention programs should include an instruction component for parents (or other caregivers) that reinforces what the children are learning, such as facts about drugs and their harmful effects.
Additional Resources -- For additional research findings about the impact of prevention, visit the NIDA web site, www.nida.nih.gov/DrugPages/Prevention.html, where you will learn facts such as, “For every $1 spent on drug use prevention, communities can save $4 to $5 in costs for drug abuse treatment and counseling.”
See the Prevention web site of the Office of National Drug Control Policy (2004). Available from www.whitehousedrugpolicy.gov/prevent.
For a review of the current research on prevention programs and their effectiveness, see the web site of the Research supporting alternatives to current drug prevention education for young people.
Available from www.drugpolicy.org/library/skager_drug_ed2003.cfm.
RELAPSE PREVENTION
Recovery, typically defined as abstinence from mood-altering substances, plus a full return to biopsychosocial functioning, involves six stages (Gorski & Kelley, 2002):
1. Abstaining from alcohol and other drugs
2. Separating from people, places, and things that promote the use of alcohol or drugs, and establishing a social network that supports recovery
3. Stopping self-defeating behaviors that prevent awareness of painful feelings and irrational thoughts
4. Learning how to manage feelings and emotions responsibly without resorting to compulsive behavior or the use of alcohol or drugs
5. Learning to change addictive thinking patterns that create painful feelings and self-defeating behaviors
6. Identifying and changing the mistaken core beliefs about oneself, others, and the world that promote irrational thinking
Relapse, the return to a familiar dysfunctional lifestyle, typically involves renewed dependence on chemical use, physical or emotional collapse, or suicide (Doweiko, 2002).
The relapsing individual usually experiences progressively increasing distress leading to physical or emotional collapse. Relapse management helps prevent a “slip” (one incident) from becoming a full-blown relapse (Curry & McBride, 1994).
As many as half of those in recovery relapse within the first 3 months after becoming abstinent (Hunt, Barnett, & Branch, 1971). Relapse episodes are usually preceded by observable warning signs.
These include:
• Being in the presence of drugs or alcohol, drug or alcohol users, or places where chemicals are used or bought
• Painful feelings (sadness, loneliness, guilt, fear, anxiety, and especially anger)
• Positive feelings, a cause for celebration
• Boredom
• Getting high on any drug
• Physical pain
• Listening to drinking/drugging “war stories” and dwelling on getting high
• Suddenly having a lot of cash
• Using prescription drugs that produce a high even if used properly
• Complacency, believing there is no longer cause to worry (Support System Homes, www.drug-rehabilitation.com/relapse_signs.htm).
Relapse prevention involves helping recovering clients recognize warning signs of relapse (Annis & Davis, 1989). Clients are at greater risk when symptoms intensify and they do not have a prevention plan (Gorski & Kelley, 2002).
Additional Resources -- For a wealth of information on Relapse Prevention, visit the web site at Narcotics and Alcohol Services for Addiction Recovery/Network International-Coalition.
Available from www.nasarecovery.com/relapsepreventionkit.html.
Two popular relapse prevention models used today are (1) Marlatt and Gordon’s Relapse Prevention Model (RP) and (2) Gorski’s Center for Applied Sciences (CENAPS) Model.
MARLATT AND GORDON’S RELAPSE PREVENTION MODEL
Based on the observation that relapse is the most frequent outcome of any treatment for substance abuse, Alan Marlatt and Judith Gordon developed this relapse model rooted in social learning theory and cognitive psychology.
Marlatt’s earlier research asked (1978) clients to describe the situation(s) that precipitated their relapse. Marlatt and Gordon (1980) classified these high-risk situations into categories; the three named most frequently accounted for nearly threefourths of the relapses: (1) negative emotional states, (2) social pressure, and (3) interpersonal conflict.
The RP model helps clients (1) anticipate and identify high-risk situations, (2) develop skills to effectively deal with those situations, and (3) confidently expect that using these skills will result in a positive outcome (Marlatt, 1983).
The RP approach also helps clients minimize damage by reacting quickly and effectively, reframing it as a slip, an unfortunate but isolated incident rather than a confirmation of a deep inability to recover (Marlatt & George, 1984).
Additional Resources -- For an outstanding overview and explanation of the RP model, see Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention: A self-control strategy for the maintenance of behavior change. New York: Guilford Press.
For a clear and concise review of Relapse prevention therapy: A cognitivebehavioral approach written by G. A. Parks & Marlatt, G. (2000), go to the National Psychologist web site.
Available from http://nationalpsychologist.com/articles/art_v9n5_3.htm.
GORSKI’S CENAPS RELAPSE MODEL
The Gorski relapse prevention model, grounded in cognitive-behavioral psychology, involves these six stages of recovery:
1. Transition: The individual recognizes problems but tries to surmount them by controlling his or her substance use.
2. Stabilization: The individual decides to refrain from substance use completely and recuperates over an extended length of time (6 to 18 months).
3. Early recovery: The individual becomes comfortable with being abstinent.
4. Middle recovery: The individual repairs past damage caused by his or her substance use and develops a balanced lifestyle.
5. Late recovery: The individual overcomes barriers to healthy living that stem from childhood experiences.
6. Maintenance: The individual recognizes a need for continued growth and for balanced living (Correctional Service of Canada, Relapse Techniques, n.d., para. 7).
This approach, deriving from Gorski’s clinical work as a chemical dependency counselor, assumes that recovery will be punctuated by setbacks—“getting stuck on the road to recovery” (Gorski, 1989, p. 5).
A restatement of the traditional 12-step (AA) program, aided by structured written exercises, this approach has a strong spiritual component (Correctional Service of Canada, Relapse Techniques, n.d., para. 10).
Additional Resources -- To learn more about this relapse prevention model see Gorski, T., & Miller, M. (1982). Counseling for relapse prevention. Independence, MO: Independence Press.
For detailed information about Gorski’s model and training visit his web site at www.cenaps.com.
THE TRADITIONAL CLASSIFICATION
This historical classification includes (1) primary prevention, (2) secondary prevention, and (3) tertiary prevention (Pransky, 1991).
PRIMARY PREVENTION Implemented before a person begins using drugs, the intent is to prevent drug use completely, or at least delay consumption.
Examples of primary prevention include educational seminars, reading materials, school instruction, marketing information, community awareness programs, help lines, changes in the laws and regulations to make drugs less easily available, and instruction in coping and life skills.
SECONDARY PREVENTION Implemented after a person has experimented with drugs, the objective is to discourage escalation into more frequent or habitual use.
Examples of secondary prevention include strengthening families, helping parents become aware of the signs and symptoms of substance abuse, medical staff intervention at first signs of drug use, harm reduction programs, and public education to increase awareness about caring for a drug-using person.
TERTIARY PREVENTION Implemented after drug use has become a problem, the goal is to help the addicted person recover, or minimally, to reduce the harm resulting from drug use and to keep the addiction from worsening.
Examples of tertiary prevention include educating the public about the long-term consequences of alcohol and drug addiction, home care programs for individuals who can no longer care for themselves because of damages incurred with heavy use, and educating addicted people about safe needle exchange techniques.
Additional Resources -- See more on prevention by visiting the web site of the Division on Prevention, Public Health Service Office of Public Health and Science. Available from http://phs.os.dhhs.gov/ophs.
See also Coombs, R. H. & Ziedonis, D. (Eds.). (1995). Handbook on drug abuse prevention: A comprehensive strategy to prevent the abuse of alcohol and other drugs. Needham Heights, MA: Allyn & Bacon.
An outstanding prevention resource is provided at http://p2001.health.org/Ms03/PAM1SLID2.htm.
Also see the www.DrugsAlcohol.info web site for useful information on drug prevention, levels of prevention, and a list of references: www.drugsprevention.net/drugs/printpage.asp?d=G3.
THE INSTITUTE OF MEDICINE CLASSIFICATION
The Institute of Medicine (1989) proposed a newmodel of prevention types. Based on Gordon’s (1987) operational classification of disease prevention, this new model has three parts—prevention, treatment, and maintenance. It subdivides the prevention category into three types: universal, selective, and indicated.
UNIVERSAL PREVENTION -- Focusing on large populations (e.g., national, local community, school, or neighborhoods), these efforts seek to prevent or delay illicit drug use. An example is creating a prevention program for all students at a given school or school district.
SELECTIVE PREVENTION -- The focus is on specific populations known to be at great risk for substance abuse, such as targeting children of drug users or poor school achievers.
INDICATED PREVENTION -- These interventions are directed at those who have already experimented with drugs or who exhibit other risk-related behaviors. Examples include such welldocumented programs as Project STAR and Adolescent Alcohol Prevention Trial.
Other examples can be reviewed at National Institute on Drug Abuse, Prevention Research (n.d.). Available from www.nida.nih.gov/DrugPages/Prevention.html.
Additional Resources -- For more information on the Institute of Medicine go to www.iom.edu. See a detailed list of indicated prevention programs.
Available from www.unf.edu/dept/fie/sdfs/program_inventory/list.html.
PREVENTION PRINCIPLES
Prevention programs typically focus on three elements: (1) The person (e.g., prior drug use, skills, physiological reactions, and perceptions), (2) the situation (e.g., peer influence, family influence, opportunity, and social norms), and (3) the environment (e.g., access, media impact, schools, and community policies, and financial factors).
The last two—situation and environment—have proven the most effective target areas for designing addiction prevention programs (McCrady & Epstein, 1999).
Categories of risk factors include the following:
• Community: Access to drugs and firearms, community laws, and norms favorable toward drug use, crime, media portrayals of violence, transition and mobility, low neighborhood attachment and community disorganization, and extreme economic deprivation
• Family: Family history of problembehaviors, family management problems, family conflict, favorable parental attitude, and involvement in problembehaviors
• School: Early and persistent antisocial behavior, academic failure beginning in late elementary school, and lack of commitment to school
• Individual/peer: Alienation and rebelliousness, friends who engage in the problem behavior; favorable attitude toward the problem behavior; early initiation of the problem behavior and constitutional factors (Hogan Gabrielsen, Luna, & Grothaus, 2003, pp. 16–17)
Some headway is being made in understanding what constitutes effective prevention message presentation and content. A meta-analysis of 120 school-based preventive interventions for 5th- through 12th-grade students indicated that interactive programs change drug knowledge, attitudes, and behaviors, whereas noninteractive programs change only knowledge.
Prevention research has addressed how to encourage program participation, why programs are more or less effective, and how prevention interventions can have positive and negative effects (Gorski, 1989).
For optimal success, program planners and implementers should include:
• Flexibility scheduling
• Reduction of initial time commitments; active involvement of both parents and peers
• Multiple positive rewards aligned to the target population, such as: free food coupons, refreshments, and child care (Spoth, Redmond, & Shin, 1998)
The multidisciplinary prevention research program (NIMH Prevention Research at www.drugabuse.gov/DrugPages/Prevention.html) of theNational Institute on Drug Abuse (NIDA) released a set of prevention principles that enumerate what has been learned through 20 years of research.
Here are a few examples:
• Prevention programs should target all forms of drug use, including tobacco, alcohol, marijuana, and inhalants.
• Prevention programs should include skills to resist drugs when offered, strengthen personal commitments against drug use, and increase social competency.
• Prevention programs should include an instruction component for parents (or other caregivers) that reinforces what the children are learning, such as facts about drugs and their harmful effects.
Additional Resources -- For additional research findings about the impact of prevention, visit the NIDA web site, www.nida.nih.gov/DrugPages/Prevention.html, where you will learn facts such as, “For every $1 spent on drug use prevention, communities can save $4 to $5 in costs for drug abuse treatment and counseling.”
See the Prevention web site of the Office of National Drug Control Policy (2004). Available from www.whitehousedrugpolicy.gov/prevent.
For a review of the current research on prevention programs and their effectiveness, see the web site of the Research supporting alternatives to current drug prevention education for young people.
Available from www.drugpolicy.org/library/skager_drug_ed2003.cfm.
RELAPSE PREVENTION
Recovery, typically defined as abstinence from mood-altering substances, plus a full return to biopsychosocial functioning, involves six stages (Gorski & Kelley, 2002):
1. Abstaining from alcohol and other drugs
2. Separating from people, places, and things that promote the use of alcohol or drugs, and establishing a social network that supports recovery
3. Stopping self-defeating behaviors that prevent awareness of painful feelings and irrational thoughts
4. Learning how to manage feelings and emotions responsibly without resorting to compulsive behavior or the use of alcohol or drugs
5. Learning to change addictive thinking patterns that create painful feelings and self-defeating behaviors
6. Identifying and changing the mistaken core beliefs about oneself, others, and the world that promote irrational thinking
Relapse, the return to a familiar dysfunctional lifestyle, typically involves renewed dependence on chemical use, physical or emotional collapse, or suicide (Doweiko, 2002).
The relapsing individual usually experiences progressively increasing distress leading to physical or emotional collapse. Relapse management helps prevent a “slip” (one incident) from becoming a full-blown relapse (Curry & McBride, 1994).
As many as half of those in recovery relapse within the first 3 months after becoming abstinent (Hunt, Barnett, & Branch, 1971). Relapse episodes are usually preceded by observable warning signs.
These include:
• Being in the presence of drugs or alcohol, drug or alcohol users, or places where chemicals are used or bought
• Painful feelings (sadness, loneliness, guilt, fear, anxiety, and especially anger)
• Positive feelings, a cause for celebration
• Boredom
• Getting high on any drug
• Physical pain
• Listening to drinking/drugging “war stories” and dwelling on getting high
• Suddenly having a lot of cash
• Using prescription drugs that produce a high even if used properly
• Complacency, believing there is no longer cause to worry (Support System Homes, www.drug-rehabilitation.com/relapse_signs.htm).
Relapse prevention involves helping recovering clients recognize warning signs of relapse (Annis & Davis, 1989). Clients are at greater risk when symptoms intensify and they do not have a prevention plan (Gorski & Kelley, 2002).
Additional Resources -- For a wealth of information on Relapse Prevention, visit the web site at Narcotics and Alcohol Services for Addiction Recovery/Network International-Coalition.
Available from www.nasarecovery.com/relapsepreventionkit.html.
Two popular relapse prevention models used today are (1) Marlatt and Gordon’s Relapse Prevention Model (RP) and (2) Gorski’s Center for Applied Sciences (CENAPS) Model.
MARLATT AND GORDON’S RELAPSE PREVENTION MODEL
Based on the observation that relapse is the most frequent outcome of any treatment for substance abuse, Alan Marlatt and Judith Gordon developed this relapse model rooted in social learning theory and cognitive psychology.
Marlatt’s earlier research asked (1978) clients to describe the situation(s) that precipitated their relapse. Marlatt and Gordon (1980) classified these high-risk situations into categories; the three named most frequently accounted for nearly threefourths of the relapses: (1) negative emotional states, (2) social pressure, and (3) interpersonal conflict.
The RP model helps clients (1) anticipate and identify high-risk situations, (2) develop skills to effectively deal with those situations, and (3) confidently expect that using these skills will result in a positive outcome (Marlatt, 1983).
The RP approach also helps clients minimize damage by reacting quickly and effectively, reframing it as a slip, an unfortunate but isolated incident rather than a confirmation of a deep inability to recover (Marlatt & George, 1984).
Additional Resources -- For an outstanding overview and explanation of the RP model, see Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention: A self-control strategy for the maintenance of behavior change. New York: Guilford Press.
For a clear and concise review of Relapse prevention therapy: A cognitivebehavioral approach written by G. A. Parks & Marlatt, G. (2000), go to the National Psychologist web site.
Available from http://nationalpsychologist.com/articles/art_v9n5_3.htm.
GORSKI’S CENAPS RELAPSE MODEL
The Gorski relapse prevention model, grounded in cognitive-behavioral psychology, involves these six stages of recovery:
1. Transition: The individual recognizes problems but tries to surmount them by controlling his or her substance use.
2. Stabilization: The individual decides to refrain from substance use completely and recuperates over an extended length of time (6 to 18 months).
3. Early recovery: The individual becomes comfortable with being abstinent.
4. Middle recovery: The individual repairs past damage caused by his or her substance use and develops a balanced lifestyle.
5. Late recovery: The individual overcomes barriers to healthy living that stem from childhood experiences.
6. Maintenance: The individual recognizes a need for continued growth and for balanced living (Correctional Service of Canada, Relapse Techniques, n.d., para. 7).
This approach, deriving from Gorski’s clinical work as a chemical dependency counselor, assumes that recovery will be punctuated by setbacks—“getting stuck on the road to recovery” (Gorski, 1989, p. 5).
A restatement of the traditional 12-step (AA) program, aided by structured written exercises, this approach has a strong spiritual component (Correctional Service of Canada, Relapse Techniques, n.d., para. 10).
Additional Resources -- To learn more about this relapse prevention model see Gorski, T., & Miller, M. (1982). Counseling for relapse prevention. Independence, MO: Independence Press.
For detailed information about Gorski’s model and training visit his web site at www.cenaps.com.
