The relapse prevention model, which was developed by Marlatt and Gordon1 and followed up by Terry Gorski2 and has been widely used in recent years in addiction treatment programs, has been the focus of considerable research. This model suggests that both immediate determinants (such as high-risk situations, coping skills and outcome expectancies) and covert antecedents (such as lifestyle factors, urges and cravings) can contribute to relapse.
In contrast to traditional theories, a model called the biopsychosocial (BPS) model has been developed to explain the complex interaction among the biological, psychological and social aspects of addiction. Donovan3 and Wallace4 articulated the BPS model for addictive behaviors in 1990 and 1999. They recognized that drinking behavior and alcohol problems are multidimensional. By expanding the “BPS” to “BPSE,” a biopsychosocial education model, we have taken the natural step of including education as a variable in relapse prevention theory.
This article describes the educational alpha test we conducted this year with 12 men and women ages 18 to 25 during an intensive outpatient program (IOP) at Lifescape Solution in Delray Beach, Fla. The test classroom was conducted over a six-week period for four hours twice per week. While the results are not statistically significant, they do call for examining a larger population in a beta test.
Wanting to resume education
The basic hypothesis we started with was to suggest that 18-to-25 year olds were relapsing in part because when they left rehab they went back to their old life in familiar surroundings with old friends. Nothing had changed in their world.
Many of these young men and women had not finished high school. Some clients started college and then dropped out. The wreckage of their past was getting in the way of their future. Many had been through rehab several times. They wanted to do something different this time. In particular, clients appeared to be looking for more intellectual stimulation.
In cooperation with therapists and caseworkers in the IOP, a classroom was set up and an environment with specific ground rules was created. The time had to be treated as inviolable, with no interruptions—no cell phones, no cross talk, and no sleeping. There were managed breaks. The clients were to be treated as students, and were required to act like committed students from 1 p.m. to 5 p.m. Mondays and Tuesdays for six weeks. There was a face-to-face learning load of a full 48 hours as well as required homework assignments.
The teaching approach used the andragogy principle5 with Freire’s concept of not turning participants into “receptacles” to be “filled” by the teacher, but rather seeing students and teachers as learners and instructors simultaneously.6 We valued the experiences the participants came with, and we applied adult learning principles in our presentation.
The students were to earn a certificate upon completion of the course. The course content was constructed to provide positive reinforcement of progress and was built to prepare a student to apply to a two-year college or vocational school, or to obtain a GED before moving forward.
Special emphasis was placed on writing skills, critical thinking, goal setting and time management. There was a full array of class interaction activities. Each student created achievable written goals for the class, with timelines for completion and weekly progress reports to peer groups and faculty.
It quickly became obvious that there was a strong sense of inadequacy and self-doubt among the students. This issue was addressed with weekly assessment of writing progress, and positive movement toward goals was constantly reinforced.
Although our study population was small, the qualitative results were encouraging. Of the 12 students who started the program, one did drop out in the first week. Below are the results for the other 11 students so far.
|Male Student 1 Sal||In Program||Vocational School|
|Male Student 2 Brian||In Program||Vocational School|
|Male Student 3 Pat||Work||Two Year College|
|Male Student 4 Ryan||Work|
|Male Student 5 Jake||In Program||Two Year College|
|Male Student 6 JJ||Sent Home|
|Male Student 7 Andrew||Work||GED|
|Female Student 1 Alyssa||Internship||Two Year College|
|Female Student 2 Steph||Sent Home|
|Female Student 3 Paige||Sent Home|
|Female Student 4 Sam||Work|
As the concept of a beta test was to be structured, it was observed that the four-hour class model that was used was too long. We recommend that moving forward, the course should be reduced to four weeks and two hours per session. It is also recommended that a math component be added to the current curriculum; the existing elements of the curriculum appear to have been well-received.
During the alpha test, classes had been conducted after a two-to-three hour intensive educational/treatment session and a lunch break. Participants struggled with separating out the intensive morning session from the academic presentations. It is recommended that two-hour early-evening sessions are conducted; this will demonstrate a clear sense of separation from the clinical concepts of the treatment program.