Cognitive Impairment and Recovery From Alcoholism

April 30, 2012

Introduction by Terence T. (Terry Gorski)

I first introduced the concept of Post Acute Withdrawal (PAW) in training programs that I presented starting in 1976 and the concept was originally published in the first edition of book Learning To Living Again – A Guide for Recovery From Alcoholism 

The concept of PAW was based upon a combination of clinical experience with relapse-prone alcoholics and a small but growing literature published by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) which was suggesting long-term neuropsychological impairment in recovering alcoholics. These impairments made it difficult for alcoholics to respond to traditional addiction counseling, even when advances in the cognitive therapy field were specifically adapted to alcoholism treatment.

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The use of harsh confrontation, which was common in the treatment of alcoholics and drug addicts in the 1970’s, actually increased client denial and defensiveness, decreased the ability of recovering people to hear understand and integrate new information. The client got stuck in recovery was unable to progress in recovery, and became increasing frustrated. Symptoms if increased stress were obvious, but clients were unable to respond to the relaxation and stress management training which was just starting come of age. I coined the word stuck point to describe this inability to progress in recovery in spite of attempts to do so.

Once the client got stuck their stress increased and a predictable pattern of early warning signs became apparent. In a future article I will present the independent research which resulted in the AWARE Questionnaire, which confirmed and refined the ability to recognize the early warning signs of relapse.

The stuck point led to increased stress. The high stress, in turn, increased frustration and a morbid fear of inevitable failure. Since alcohol and drug use had be so destructive in the past, the fear of relapse activated a survival threat seemed to decrease the ability to think clearly and learn new information and skills. The relapsing people usually failed to understand what was happening and judged themselves as dumb, stupid, and unable to recover. Therapist often failed to recognize the neuropsychological basis of the symptoms, mislabeled it as denial and resistance and proceed to confront the client. The confrontation just made things worse. Other therapists decided the neurocognitive impairment was caused by unresolved family of origin problems and used deep relaxation and guided imagery to resolve trauma from previous physical or sexual abuse. This of course, was the hallmark of the codependency era.

The use of confrontation, regressive hypnosis, and catharsis techniques all increased the stress of clients, lowered their self-esteem by making them feel crazy, and decreased their self-confidence. This lack of self-confidence or absence of the positive belief in their ability to successfully recover was later dubbed low efficacy by cognitive therapists such as Alan Marlatt, Dennis Donovan, and Dennis Miller.

Convincing evidence began to develop that low efficacy was directly related with an increase in early relapse warning signs and the eventual failure to maintain recovery. The final trigger event was a high risk situation which activated craving in an environment that reinforced alcohol use while removing support for ongoing recovery.

Alan Marlatt observed the same thing. He originally described the phenomenon of apparently irrelevant decisions, which, in essence, described the same phenomena that I described as early relapse warning signs.

Both concepts were pointing at the same thing – symptoms caused progressive neuropsychology or neurocognitive dysfunction related to the stress of feeling stuck in a dysfunctional state and slowly becoming so dysfunctional and having no effective way to manage the growing inability to function. This produced a survival threat. We now know that high levels of stress activates the amygdala in the brain. The amygdala would shift behavioral control from slow-moving conscious decision-making to automatic use of emergency survival skills.

I labeled this progressive stress-induced dysfunction as the relapse syndrome.

The relapse syndrome was a progression of early warning signs of relapse  that ended in a high risk situation which activated craving, drug-seeking behavior, exposure to high risk situations, and the return to using alcohol and or other drugs.

The bottom line is this. In 2008 a compelling body of evidence exists that there is progressive brain dysfunction in alcoholic clients. This brain dysfunction is measureable and supported in the scientific literature. What follows is the research verification for the Post Acute Withdrawal Syndrome (PAW) Syndrome. This evidence is summarized in the following Alcohol Alert.

National Institute on Alcohol Abuse and Alcoholism

Alcohol Alert, No. 53 – July 2001

 Brain damage is a common and potentially severe consequence of long-term, heavy alcohol consumption. Even mild-to-moderate drinking can adversely affect cognitive functioning (i.e., mental activities that involve acquiring, storing, retrieving, and using information) (1). Persistent cognitive impairment can contribute to poor job performance in adult alcoholics, and can interfere with learning and academic achievement in adolescents with an established pattern of chronic heavy drinking (2). A small but significant proportion of the heaviest drinkers may develop devastating, irreversible brain-damage syndromes, such as Wernicke-Korsakoff syndrome, a disorder in which the patient is incapable of remembering new information for more than a few seconds (3).

It stands to reason that cognitive impairment also may impede recovery from alcoholism, although evidence has not conclusively shown this to be the case.  For example, Morgenstern and Bates (4) studied whether deficits in a patient’s learning and planning abilities-core aspects of many treatment strategies-affected recovery from alcoholism. They found that impairment was not a significant predictor of poor treatment response. On the other hand, evidence does support the possibility that brain damage, whether resulting from or predating alcohol use, may contribute to the development and progression of alcoholism (5).

Designing practical strategies to cope with the complex combination of alcoholism and cognitive impairment requires an understanding of the nature of cognitive functions and their interactions with structural and functional brain abnormalities. This issue of Alcohol Alert describes the nature and consequences of common alcohol-associated cognitive defects, explores the extent to which some cognitive abilities recover with abstinence, and summarizes recent research on the effects of cognitive deficits on alcoholism treatment outcome.

Cognition and Alcohol

Most alcoholics exhibit mild-to-moderate deficiencies in intellectual functioning (6), along with diminished brain size and regional changes in brain-cell activity. The most prevalent alcohol-associated brain impairments affect visuospatial abilities and higher cognitive functioning (7). Visuospatial abilities include perceiving and remembering the relative locations of objects in 2- and 3-dimensional space. Examples include driving a car or assembling a piece of furniture based on instructions contained in a line drawing. Higher cognitive functioning includes the abstract-thinking capabilities needed to organize a plan, set it in motion, and change it as needed (2).

Most alcoholics entering treatment perform as well as nonalcoholics on tests of overall intelligence. However, alcoholics perform poorly on neuropsychological tests that measure specific cognitive abilities (8). For example, an alcoholic who has remained abstinent after treatment may have no apparent difficulty filing office documents correctly, a task that engages multiple brain regions. However, that same person might be unable to devise a completely different filing system, a task closely associated with higher cognitive functioning.

How Much Is Too Much?

The link between duration and lifetime quantity of drinking and the development of cognitive problems is unclear. Some investigators have proposed that cognitive performance worsens in direct proportion to the severity and duration of alcoholism (6,9). Studies suggest that social drinkers who consume more than 21 drinks per week also fit into this category (6). Other investigators have suggested that cognitive deficits may be detectable only in those alcoholics who have been drinking regularly for 10 years or more (8,10). Long-term, light-to-moderate social drinkers have been found to fall into this category as well, showing cognitive deficits equivalent to those found in detoxified alcoholics (8). Although further research is needed to determine how a person’s pattern of drinking is related to cognitive impairment, some deficits are possible even in people who are not heavy drinkers.

Tracking Structural and Functional Brain Abnormalities

Structural and functional brain abnormalities generally are measured by noninvasive imaging techniques that provide a picture of the living brain with minimal risk to the individual. Structural imaging techniques, such as computed tomography and magnetic resonance imaging, are used to generate computerized pictures of living tissue. Functional imaging techniques, such as positron emission tomography and magnetic resonance spectroscopy, permit scientists to study cell activity by tracking blood flow and energy metabolism. For more information about imaging, see Alcohol Alert No. 47, “Imaging and Alcoholism: A Window on the Brain.”

Structural imaging consistently reveals that compared with nonalcoholics, most alcoholics’ brains are smaller and less dense (11,12). Loss of brain volume is most noticeable in two areas: the outer layer (i.e., the cortex) of the frontal lobe, which is considered a major center of higher mental functions (7,12,13); and the cerebellum, which is responsible largely for gait and balance as well as certain aspects of learning (14). Support for these results is provided by functional imaging studies, which reveal altered brain activity throughout the cortex and cerebellum of heavy drinkers (15). In addition, functional imaging often is sufficiently sensitive to detect these irregularities before they can be observed by structural imaging techniques, and even before major cognitive problems themselves become manifest. This suggests that functional imaging may be particularly useful for detecting the early stages of cognitive decline (15).

Understanding the Basis of Cognitive Impairment

Accurate measurement of cognitive abilities is challenging, and relating those abilities to a specific brain irregularity simply may not be possible with the current technology (16). Discrepancies among research findings have led scientists to develop improved cognitive-measuring techniques. Using a battery of tests, Beatty and colleagues (9) have suggested that widespread (i.e., diffuse) cognitive impairment could arise from damage to multiple brain areas, each of which regulates distinct but related abilities. Likewise, damaging the network of brain cells that synchronizes the overall activity of those multiple areas may produce the same cognitive impairments previously attributed to localized damage (9).

Is Impairment Reversible?

Certain alcohol-related cognitive impairment is reversible with abstinence (17). Newly detoxified adult alcoholics often exhibit mild yet significant deficits in some cognitive abilities, especially problem-solving, short-term memory, and visuospatial abilities (18). By remaining abstinent, however, the recovering alcoholic will continue to recover brain function over a period of several months to 1 year (19)-with improvements in working memory, visuospatial functioning, and attention-accompanied by significant increases in brain volume, compared with treated alcoholics who have subsequently relapsed to drinking (18).

Rewiring Brain Networks

Reversibility of alcohol-related cognitive function also may be the result of a reorganization of key brain-cell networks. Some researchers have proposed that such reorganization may contribute to the success of alcoholism treatment. Using advanced imaging techniques, Pfefferbaum and colleagues (20) examined the brain activity of cognitively impaired alcoholic participants during a series of tests designed to assess cognitive function. They found that although the alcoholic subjects had abnormal patterns of brain activation, compared with control subjects, they were able to complete the tasks equally well, suggesting that the brain systems in alcoholics can be functionally reorganized so that tasks formerly performed by alcohol-damaged brain systems are shunted to alternative brain systems.  This finding-that cognitively impaired alcoholic patients use different brain pathways than unimpaired patients to achieve equivalent outcome-also was suggested in a study of patients in 12-step treatment programs (4). Functional brain reorganization may be particularly advantageous for adolescent alcohol abusers in treatment, because their developing brains are still in the process of establishing nerve-cell networks (21).

Cognitive Function and Alcoholism Treatment

The exact role that cognitive function has in alcoholism treatment success is unclear. Structural and functional imaging, as well as more specific cognitive tests, may provide scientists with the tools needed to reveal subtle relationships between alcohol-related cognitive impairment and recovery. Meanwhile, certain conclusions can be drawn from existing research that help to explain how cognitive function may influence alcoholism treatment:

Cognitive deficits have been hypothesized to affect the efficacy of alcoholism treatment, although a clear association has not been established. One view finds that cognitively impaired patients may not be able to comprehend the information imparted during therapy and, thus, may not make full use of the strategies presented, thereby hampering recovery. Another view is that cognitive functioning may not directly influence treatment outcome, but may impact other factors that, in turn, contribute to treatment success (22). Focusing on those factors-such as improved nutrition, opportunities for exercise, careful evaluation of comorbid mental or medical disorders, and/or treatment strategies aimed at enticing the patient out of long-standing social isolation-ultimately may be more beneficial than focusing exclusively on recovery from alcoholism.

Other types of non-alcohol-related brain damage also can produce symptoms resembling those associated with chronic alcoholism. Clinicians must be aware that no matter the cause of the impairment, it may have an impact on the patient’s ability to benefit fully from alcohol-treatment strategies. Cognitive impairment is usually most severe during the first weeks of abstinence, perhaps making it difficult for some alcoholics to benefit from educational and skill-development sessions, which are important components of many treatment programs (22,23). For example, one study found that alcoholics tested soon after entering treatment were unable to recall treatment-related information presented in a film they had just been shown (4). As time goes by and cognitive function improves, however, patients may make better use of information presented to them in individual and group therapy, educational programs, and 12-step programs.

Cognitive Impairment and Recovery From Alcoholism-
A Commentary by NIAAA Director Enoch Gordis, M.D.

The new noninvasive imaging techniques that allow us to “see” how the brain operates have been a boon to the study of cognition. Through this medium, we now know that the brain is capable of “rewiring” itself. In doing so, the brain can regain some of the cognitive abilities previously diminished as a result of damage from alcohol or other diseases. The brain’s remarkable ability to recover is important for at least two reasons. First, alcohol use over a period of time, even at low levels of drinking, can produce varying degrees of cognitive damage, a problem that is of particular concern because alcohol use is so widespread. Thus, the brain’s self-repairing ability may help defer or reduce alcohol-induced cognitive problems among a large portion of the population. Second, the brain’s ability to rewire itself may have implications in terms of adolescent drinking. Recent evidence suggests that the adolescent brain, which is still forming important cellular connections, is more vulnerable than the adult brain to alcohol-induced damage. This is particularly troubling, given the problems associated with chronic binge drinking, which is all too common among young people. The brain’s ability to rewire important neurological systems might help mitigate a lifetime of cognitive difficulties resulting from chronic drinking during adolescence, but we do not yet know if this is true. Future research will help clarify this and other important questions about alcohol’s effect on cognition.


(1) Evert, D.L., and Oscar-Berman, M. Alcohol-related cognitive impairments: An overview of how alcoholism may affect the workings of the brain. Alcohol Health Res World 19(2):89-96, 1995. (2) Giancola, P.R., and Moss, H.B. Executive cognitive functioning in alcohol use disorders. In: Galanter, M., ed. Recent Developments in Alcoholism: Volume 14. The Consequences of Alcoholism.New York: Plenum Press, 1998. pp. 227-251. (3) Oscar-Berman, M. Severe brain dysfunction: Alcoholic Korsakoff’s syndrome. Alcohol Health Res World 14(2):120-129, 1990. (4) Morgenstern, J., and Bates, M.E. Effects of executive function impairment on change processes and substance use outcomes in 12-step treatment. J Stud Alcohol 60(6)846-855, 1999. (5) Bowden, S.C.; Crews, F.T.; Bates, M.E.; et al. Neurotoxicity and neurocognitive impairments with alcohol and drug-use disorders: Potential roles in addiction and recovery. Alcohol Clin Exp Res 25(2):317-321, 2001. (6) Parsons, O.A. Neurocognitive deficits in alcoholics and social drinkers: A continuum? Alcohol Clin Exp Res 22(4):954-961, 1998. (7) Oscar-Berman, M.; Shagrin, B.; Evert, D.L.; and Epstein, C. Impairments of brain and behavior: The neurological effects of alcohol. Alcohol Health Res World 21(1):65-75, 1997. (8) Parsons, O.A., and Nixon, S.J. Cognitive functioning in sober social drinkers: A review of the research since 1986. J Stud Alcohol 59(2):180-190, 1998. (9) Beatty, W.W.; Tivis, R.; Stott, H.D; Nixon, S.J.; and Parsons, O.A. Neuropsychological deficits in sober alcoholics: Influences of chronicity and recent alcohol consumption. Alcohol Clin Exp Res 24(2):149-154, 2000. (10) Eckardt, M.J.; File, S.E.; Gessa, G.L.; et al. Effects of moderate alcohol consumption on the central nervous system. Alcohol Clin Exp Res 22(5):998-1040, 1998. (11) Pfefferbaum, A.; Rosenbloom, M.; Crusan, K.; and Jernigan, T.L. Brain CT changes in alcoholics: Effects of age and alcohol consumption. Alcohol Clin Exp Res 12(1):81-87, 1988. (12) Pfefferbaum, A.; Lim, K.O.; Zipursky, R.B.; et al. Brain gray and white matter volume loss accelerates with aging in chronic alcoholics: A quantitative MRI study. Alcohol Clin Exp Res 16(6):1078-1089, 1992. (13) Lyvers, M. “Loss of control” in alcoholism and drug addiction: A neuroscientific interpretation. Exp Clin Psychopharmacol8(2):225-249, 2000. (14) Sullivan, E.V.; Rosenbloom, M.J.; Deshmukh, A.; et al. Alcohol and the cerebellum: Effects on balance, motor coordination, and cognition. Alcohol Health Res World 19(2):138-141, 1995. (15) Eberling, J.L., and Jagust, W.J. Imaging studies of aging, neurodegenerative disease, and alcoholism. Alcohol Health Res World 19(4):279-286, 1995. (16) Parsons, O.A. Determinants of cognitive deficits in alcoholics: The search continues. Clin Neuropsychologist 8(1):39-58, 1994. (17) Volkow, N.; Wang, G.J.; and Doria, J.J. Monitoring the brain’s response to alcohol with positron emission tomography. Alcohol Health Res World 19(4):296-299, 1995. (18) Sullivan, E.V.; Rosenbloom, M.J.; Lim, K.O.; and Pfefferbaum, A. Longitudinal changes in cognition, gait, and balance in abstinent and relapsed alcoholic men: Relationships to changes in brain structure. Neuropsychology 14(2):178-188, 2000a. (19) Sullivan, E.V.; Rosenbloom, M.J.; and Pfefferbaum, A. Pattern of motor and cognitive deficits in detoxified alcoholic men. Alcohol Clin Exp Res 24(5):611-621, 2000 b. (20) Pfefferbaum, A.; Desmond, J.E.; Galloway, C.; et al. Reorganization of frontal systems used by alcoholics for spatial working memory: An fMRI study. NeuroImage 13:1-14, 2001. (21) Spear, L. Modeling adolescent development and alcohol use in animals. Alcohol Res Health 24(2):115-123, 2000. (22) Allen, D.N.; Goldstein, G.; and Seaton, B.E. Cognitive rehabilitation of chronic alcohol abusers. Neuropsych Review 7(1):21-39, 1997. (23) McCrady, B.S., and Smith, D.E. Implications of cognitive impairment for the treatment of alcoholism. Alcohol Clin Exp Res 10(2):145-149, 1986.

Helping Characteristics

April 29, 2012
By Terence T. Gorski –

Effective helpers have integrated eight basic helping characteristics into their personalities.  The effectiveness of the therapists will improve as they consistently demonstrate a broader balance of these characteristics.

In the GORSKI-CENAPS® model, these helping characteristics are also applied in Group therapy.  Since an important role of group members is to help one another solve problems, it seems reasonable that the higher the level of helping characteristics demonstrated by group members during sessions, the more effective the groups will be.  This establishes a primary goal of the group leader to encourage the development of helping characteristics in all group members by role modeling them.

1.         Empathy:  Empathy is the ability to understand how another person perceives or experiences a situation or event.  It is the ability to enter the context, mind-set, or frame of reference of another person and to perceive the world from his or her point of view.  It is also the ability to communicate your perception of how the other person is perceiving the experience.

2.         Genuineness:  Genuineness is the ability to be fully yourself and to express your unique individual style and personality to another.  It is an absence of phoniness, role-playing, and defensiveness.  In a genuine person the outer behavior (the public self) matches the inner thoughts and feelings (the private self).

3.         Respect (Positive Regard):  Respect is the ability to communicate to another person, both verbally and non-verbally, the belief that he or she has the inner strength and capacity to make it in life, has the right to make his or her own decisions, and has the capacity to learn from the consequences of those decisions.

4.         Self-Disclosure:  Self-disclosure is the ability to communicate personal thoughts, feelings, attitudes, and beliefs to another person in a context appropriate manner when it is in the benefit of the other person for you to do so.

5.         Warmth:  Warmth is a non-verbal behavior that demonstrates positive regard and makes another person psychologically visible in a positive way.  Examples of behavior that communicate warmth would be touching, smiling, making eye contact, talking in a soft gentle tone of voice, etc..

6.         Immediacy:  Immediacy is the ability to focus upon the “here and now” interaction between yourself and other people.  The use of “I” statements followed by statements of personal reaction typically express immediacy.  Examples would be:  “Right now I am feeling ________.  When you said that, I began to think __________.  Right now I feel like _________.  As you were speaking, I began to sense that you were experiencing ___________.”

7.         Concreteness:  Concreteness is the ability to identify and clarify specific problems or issues.  It also includes the ability to design an action plan that describes the concrete steps that need to be solved in order to correct or resolve the problem.  Concreteness involves the ability to keep focused upon a specific problem and the action plan designed to resolve it.  It includes making clear and concrete expectations of others and inspecting the outcomes of those expectations.

8.         Confrontation:  Confrontation is the act of honestly communicating to another person your perception of reality which includes:  Your honest perception of the person’s strengths and weaknesses.  What you believe the person is thinking and feeling; How you observe the person to be acting; and What you believe are the logical consequences of those actions.  Effective confrontation communicates your view of reality to the other person in a way that supports the person while pointing out self-defeating thinking, emotional responses, behavior, and situational involvement.

Confrontation, Self-Exploration, and Helping Characteristics

Susan Anderson (Anderson, 1968) did a study that shows the relationship between the use of confrontation,  other helping characteristics (which she called facilitating conditions), and the movement of patients from confrontation to self-exploration. This article demonstrates the importance of having clear operation definitions of basic counseling procedures.

Anderson looked at the relationship between SUPPORTIVE/RATIONAL CONFRONTATION (which she simply called confrontation), the use of HELPING CHARACTERISTICS (which she called facilitating factors),  and the ability of the patient to move from Confrontation to SELF-EXPLORATION (Confrontation –> Self Exploration).

SUPPORTIVE-RATIONAL CONFRONTATION is defined as pointing out problems, self-defeating behaviors, or inconsistencies in a way that supports the person and points out the problem behavior. Anderson’s study did not allow therapists to use HARSH PSYCHO-NOXIOUS CONFRONTATION which involves angry/hostile attacks, arguing, fighting, or challenging a patient to look at problems from the therapist’s point-of-view with the intent to prove that the therapist is right or and the patient is wrong. From this point on, when I use the term confrontation, I use it to mean rational-supportive confrontation as defined above. When I use the term HELPING CHARACTERISTICS is will be used to mean the same as Anderson’s facilitating conditions.


METHOD: Tape recordings were made of 40 initial therapy interviews. A review panel of judges were trained to accurately identify the therapist’s use of CONFRONTATION and the Helping Characteristics (Five facilitating Conditions) and the patients movement from the confrontation to self exploration.

CONFRONTATION was operationally defined as “the therapist initiating interactions in which the therapist pointed out to the patient a discrepancy between his own and the client’s way of viewing a situation.” This is essentially the same as the definition of confrontation used in the first part of this article).

The HELPING CHARACTERISTICS, described as Five facilitating Conditions, were defined as: the therapist’s observable use by the judges of   the therapist’s use of: (1) Empathy,  (2) Genuineness, (3) Respect (Positive Regard), (4) Self-Disclosure, and (5) Concreteness. The characteristic warmth (part of the description of genuineness) and immediacy were not evaluated as separate categories).

SELF EXPLORATION was defined as the client’s ability to hear the therapists feedback (the content of the confrontation) accurately and discuss what aspects of the information presented in the confrontation fit or did not fit the situation being discussed.

Anderson’s study looked at the relationship between:

(1) Th number of times the therapists used CONFRONTATION

(2) The number of time the therapist used  HELPING CHARACTERISTICS, and

(3) And how frequently the use CONFRONTATION led into patient initiated SELF-EXPLORATION

HYPOTHESIS: The hypothesis was that:

(1) Confrontation would be positively related to high levels patient self-exploration, when accompanied by high levels of the helping characteristics, and

(2) Confrontation would be related to low levels of movement into self-exploration when accompanied by low levels of helping characteristics. these conditions, confrontation was never followed by increased self-exploration.


1. Patients had a high level of movement INTO self-exploration when the therapist used high levels of HELPING CHARACTERISTICS,
2. Patient’s NO NON-EXISTENT) movement from confrontation to self-exploration.  In other words, the patient NEVER moved from confrontation to self-exploration) when the therapist used low levels of HELPING CHARACTERISTICS.
3. As the use of HELPING CHARACTERISTICS increased there was an increase in the patient’s level of movement from confrontation to self-exploration.
4. There appears to be a minimal level at which the use of helping characteristics need to be used before any change in the movement from confrontation to self-exploration occurred.
5. This could be because a level of trust (defined as a consistent use helping characteristics used to support self-exploration ) requires at least a moderate use of the helping characteristics.

Anderson, Susan C., THE EFFECTS OF CONFRONTATION BY HIGH AND LOW-FUNCTIONING THERAPISTS., Journal of Counseling Psychology, Vol 15(5, Pt.1), Sep 1968, 411-416.

Carkhuff, Robert R. and Anthony, William A., The Skills of Helping, Human Resource Development Press, Amherst, Massachusetts, 1979.

Carkhuff, Robert R. and Berenson, Bernard G., Beyond Counseling and Therapy – Second Edition, Holt Rinehart, and Winston, Amherst, Massachusetts, 1977

Gorski, Terence T., The Gorski-CENAPS Model for Recovery and Relapse Prevention, Independence, Missouri: Herald House/Independence Press, 2007.

Rogers, Carl R. “The characteristics of a helping relationship.” The planning of change (1969): 153-166.

The Psychology of Long-Duration Space Flight

April 29, 2012

Introduction to the Psychology of Long-Duration Space Flight

by Terence T. (Terry) Gorski

The article below is reprinted from the NASA website (See the above link). I want to bring it to my blog to show how well grounded and practical psychological services can and needs to be an important part of mankind’s most important, exciting, and historic adventures.

Any psychological professional knows that young people need to have a compelling goal that they can be a part of. To interrupt our vision f ongoing space exploration takes away and important psychological motivation for our young people. It takes away m opportunity to say I am a part of something bigger than myself, something glorious, and something to be proud of. Many people, myself included, felt profound disappointed that we were not keeping the dream alive. The young people I have had the honor of talking with felt it also.

The frontiers of science, including the psychological sciences, can lead us to explore strange new worlds, both within us and around us. A focus upon positive psychology can show us, in real ways, how to go where no one has ever dared before.

My career was and continues to be an adventure. I want to pass the dream and vision forward to the new generation. I have had the privilege of serving in an exciting career that has taken me around the world and introduced me to some of the world’s most exciting people. I like to believe, that in some small way, I have contributed to the flow of history that is unfolding within and around me. I want to pass that an exciting vision forward. We can do something that really counts. We can make opportunities to be where the action is doing something that makes a difference

When President John F. Kennedy announced, with the full backing of congress, the ten-year goal of landing a man on the moon and safely returning him to earth, the field of psychology took a hit on the chin. Major players on NASA’s initial psychology team warned against pursuing manned spaceflight because astronauts could not maintain their psychological health during prolonged space flight. NASA responded by significantly reducing the size, scope, and role of the psychological services to screening and crisis intervention.

All exploration carries physical and psychological risks. The field of psychology needs to maintain a can-do attitude toward helping people on the cutting edge of exploration in all areas of our society. To take positions that diminish the role and importance of psychological services is not a good way to go. We need to get involved, as psychological professionals, in working with all sectors of our society, to meet human needs in the ever-changing and politically charged world. I hope this review of an exciting era in USA history can generate some enthusiasm for the new generation entering the field of psychological services. My message is simple: create a powerful vision for your future career. Step into leadership roles. Bring the principle of positive psychology strongly into play in all areas of society. Psychological professional, of all stripes and sizes, should be leading in many critical areas of our society. It is not our primary role to clean the messes made by people who ignore sound psychological principles in meeting real-world challenges.

Here is the brief history, according to NASA, of what has been learned from the integration of psychology into the challenges of space travel. Read! Marvel! Learn! Keep the dream alive in your own heart. Then actualize it. Make your dream real through action. Don’t just adjust to the insanity unfolding around you. It is what it is. You can make a difference.

“One person can make a difference. Every person should try.”
~ John F. Kennedy ~

— NASA HISTORY – The Psychology of Long-term Space Flight —

Spaceflight offers astronauts immense psychological rewards. However, long-duration spaceflight also poses great psychological risks. Dangers, deprivation, isolation, and confinement helped make the Mir residencies—in the words of some U.S. astronauts—the “hardest thing” they had ever done.

Moreover, their spaceflights came on the heels of difficult periods in Russia, where NASA astronauts trained immersed in a foreign culture and language. Add to this the fact that many NASA managers and support people were likewise experiencing lifestyle disruptions and heavy workloads, and the psychological aspect became as important as any physical aspect.

Up until Shuttle-Mir, most NASA astronauts were able to consider the physical risks before their flights. They could put [the risk] into perspective and launch with happy hearts. When dangerous situations occurred suddenly, they were usually over quickly. Even in the frightening case of Apollo 13, the crisis lasted only a few days.

With long-duration spaceflight, danger always exists; and living long in danger’s presence increases one’s awareness of it. Yet, for the most part, the Mir astronauts were able to adjust to this awareness—and even to add to their confidence in Mir’s overall safety. For example, about the collision incident that occurred during NASA-5, Mike Foale described his feelings.

“It was frightening for one or two seconds,” he said. “The first thought was—are we going to die instantly because of air rushing out so that we couldn’t control it? It was obvious within two or three seconds that the air wasn’t rushing out. Then we thought we had time, and I heard the pressure dropping. Immediately from that point, I thought ‘Oh, this is a surprisingly robust station.’”

Meanwhile on the ground, Frank Culbertson and other managers faced the danger from their perspectives. They not only had to assess the risks, but they had to assure critics in Congress and elsewhere that their assessments were correct.

Sensory deprivation is another key factor in long-duration spaceflight. It manifests itself in many ways. The first sensory element to go is the pull of gravity and its physical comfort of rootedness. On shorter Shuttle flights, the lack of gravity often remains a pleasant novelty. But, combined with the other factors, microgravity could add to a long-duration astronaut’s discomfort. However, most of the Mir astronauts reported enjoying microgravity. John Blaha said he didn’t miss the pull of gravity at all. Andy Thomas wrote that microgravity was “the one thing that makes spaceflight both interesting and, at the same time, very frustrating . . . It can be a joy to experience, but [it] also can really make your work day difficult.”

An astronaut’s sense of time could also be affected. Sunrise and sunset alternate every 45 minutes. The sleep-and-wake cycle could come to feel arbitrary. And, when one is working long hours without refreshing breaks, the passage of time could seem to expand or contract. Worse, the amount of time left in a mission could become difficult to gauge. Yet, the Mir astronauts did not relate any real problems. Jerry Linenger wrote from Mir that “life in space is never monotonous.”

But, the kind of deprivation that most affected Mir astronauts was social deprivation—being away from one’s culture and family for such an extended period. Norm Thagard talked about missing his American cultural and linguistic environment. John Blaha said what he really missed most was his wife.

Deprivation of meaningful work—or, conversely, of refreshing rest—also affected the U.S. Mir astronauts. Norm Thagard had to wait for many of his science experiments to arrive, and the Russians did not allow him much interaction with Mir’s control systems. In the words of NASA psychologist Al Holland, “The situation of work underload is one of the worst situations you can ask a high-achieving, bright, interested astronaut to subject himself to.”

Other astronauts went many days without much rest, working mainly on menial tasks such as cleanup, when they weren’t working on their American science projects. Those experiments were very important to the American astronauts. Mike Foale said, “I loved the greenhouse experiment. It didn’t matter that the shrubs were tiny . . . I enjoyed being a bee pollinating plants.

I enjoyed looking at [the plants] every morning for about 10 to 15 minutes. It was a moment of quiet time, almost. It was a moment where it was nice and bright and almost sunny in a module [Kristall] that had no power for about two months.” Foale was dubbed “Farmer Foale” by the ground-based science team for his persistence in keeping the plants alive under trying conditions.

Mir astronauts did engage in exercise and recreational activities. Shannon Lucid read books. John Blaha watched videos. Andy Thomas sketched.

With long-duration spaceflight, an astronaut does not have the freedom to go where he or she wants to, and when he or she wants to, and no one can “drop in” to see him or her. A spur-of-the-moment walk becomes a thing of the past—and, hopefully, of the future. Jerry Linenger wrote in a letter to his son, “A simple walk would be fine. Or a paddle in the canoe. Indoors won’t do. Need fresh air. Need to feel a breeze . . . the sound of wind through the trees overhead.

Before Shuttle-Mir, the Russians had years of experience with long-duration spaceflight. They had developed rigorous methods of selecting Mir crews and were able to give their selected crews psychological training. General Yuri Glaskov, Deputy Commander at the Gagarin Cosmonaut Training Center, described one of the training methods. He said, “We put our crew members into . . . an isolation chamber. I had to myself be in this chamber for 14 days.

It is called . . . ‘alone in public.’ Everybody is watching you, but you can’t see anybody. There are certain psychological nuances there because you fight yourself.”

Glaskov also experienced a 35-day ground test of the Mir orbital station. He said, “At that time, there were two of us; but the hatches were closed, and we were absolutely alone for 35 days. This experience created different problems. Here, we had to tolerate each other, forgive each other, and supplement each other’s faults or experiences. . . . One person doesn’t like certain traits of another [person], and so you have to learn to adapt to each other.”

NASA’s Shuttle-Mir astronauts were basically volunteers. While that eliminated the value of a selection process, it did give NASA psychological scientists the opportunity to observe—and to support—a range of personalities during the seven-mission program. NASA Psychologist Al Holland said, “It’s really probably good that we weren’t allowed to do selection in our usual manner beforehand, but we had to work with the people who were assigned to us to fly—because in that way we learned a lot more.”

NASA’s “flight docs” and managers worked to make the Mir astronauts’ missions as normal as possible, with things like weekly talks with family and friends; “surprise packages” coming up on Progress resupply vehicles; ham radio conversations with friends, family, and even strangers; and the crew on-orbit support system, a laptop computer and compact disks that included items such as special greetings that were timed to coincide with an astronaut’s birthday.

So, what was learned about psychology during the Shuttle-Mir experience? In the opinion of both the Russian crewmembers and American astronauts who served during Shuttle-Mir, greater attention needs to be given to matters of the psychological compatibility of crewmembers. For this, a longer training period should be carried out for each crew. And, joint training sessions for survival under extreme conditions would also help.

Holland pointed to the entire supporting organization. “One of the things that was astounding to me was that, traditionally, we had this focus on the individual. . .. We were thinking that’s where you need to put your effort. In the Mir series, what was so striking was the influence of the organizational policies and the organizational context on the individual’s psychological health. . .. There were just so many organizational lessons that were learned . . . in terms of policies and procedures,” he said.

“Basically, NASA had to learn how to deploy people and their families, and [to] make sure that people got back and forth without a lot of problems. NASA’s not like the military. It never had before deployed people for long periods of time in foreign countries, so there was no infrastructure at all to do that. We just gave them a ticket and sent them over there.”

Here is a related blog: Gene Cernan – The Last Man To Walk On The Moon

Brain Disease – Expanding Into A Unified Model

April 29, 2012

By Terence T. (Terry) Gorski

The “Brain Disease Model” of addiction is useful but limited. I believe the best model is a bio-psycho-social-spiritual model that is described in detail in my new book Straight Talk About Addiction (Check out : and )

The bio component involves “the addictive brain response” which occurs when the drug of choice activates a flood of pleasure chemicals in the brain while slowing down the production of stress other warning chemicals that give us the gift of fear which warns us of danger.

The Psycho component involves the addictive thoughts, feelings, urges and actions that drive chemical and process addictions.

The social dimension involves personal relationships, attachment to social groups for the purpose of business and recreation, and culture. It is within this social dimension where we confront the difficult issue of the group mind or group consciousness

This addictive brain response causes changes in thinking, feelings, motivations, and actions. When the addictive brain response is activated, intuition and conscience are both affected. Intuition and conscience activate automatic signals generated by brain chemistry which come from both innate characteristics (we are programmed to know right and wrong, safety from danger, what is good for me and what is bad for me on primitive felt-sense level; our conscience or moral compass) and learned moral behavior (our sense of right and wrong is refined and developed through learning and life experience. The addictive brain response distorts or shuts down both intuition and conscience.

The addictive brain response also diminishes or eliminates anxiety and fear, which are natural warning signals that we may be in danger. The addictive brain response also causes the unconscious signaling system designed to support our family of origin program, as expressed in our personality, to diminish or disappear entirely. As a result people can overcome the unhealthy inhibitions programmed into their brain chemistry responses as children. Unfortunately, when sober these old responses return.

This unique feeling of euphoria can free people from inhibitions and allows them to feel free to be who they want to be and to do what they choose to do. As the addictive disease progresses, it takes higher doses of alcohol or other drugs of choice to get the euphoric feelings. In terms of process addictions, it takes greater and greater levels of stimulation over longer periods of time to get the euphoric effect. People drink and use drugs more often and more heavily. Their lives become focused around alcohol and other drug use. They develop an addiction-centered social life, and chasing the euphoria becomes the primary concern. This is where the “social” part of biopsychosocial enters the picture.

With sobriety, the brain heals. Brain research also provides compelling evidence for brain plasticity – the term used to describe the idea that the brain grows in response to experience throughout the course of the life span. As a result specific cognitive and behavioral therapies can systematically cause the building of new neurocircuits   that support recovery and responsibility through systematical practice of specific ways of thinking and acting when under stress. As recovering people stop using addictive thoughts, behaviors, and chemicals, the addictive  that support drug-seeking behavior become weaker . The circuits that support sober and responsible behavior get stronger.  Good news, but it takes knowledge, skill, practice, and determination over a long period of time to activity neuroplastic brain growth.

Spirituality provides a critical connection with a source of courage, strength, and hope allows people to keep moving ahead in their recovery even when they don’t feel like it. It allows them to overcome cravings, face and manage fear, and find a way to stay calm in the face of the frustrations of life and living.  This is a life-long recovery process. Life is hard. Human beings die and we know that we will do so. Living in the shadow of the inevitable deaths of ourselves and our loved ones produces a background feeling of fear and pain which has been described as angst. We need courage, strength and hope that something good will come of our recovery. This sense of hope keeps on going during hard times. To keep hope alive in the face of fear and discouragement requires courage.

The Brain Disease Model of Addiction provides useful information and helpful ideas about approaching recovery. Unfortunately, fails to take into account some critical biopsychosocial aspects of recovery encompassed in nonphysical or spiritual ideas like Higher Power, group conscience, courage, strength and hope. These nonphysical dimensions of humanity is what gives people their greatest sense of meaning and purpose. We can’t yet take brain scans that show pretty pictures of these things in the brain.  Perhaps we never will! This, however, does not mean they do not exist. The spiritual aspects of recovery may not be tangible or physical. There may very well be a nonphysical mind that inhabits and takes control of the physical brain. These nonphysical aspects of humanity provide powerful experiences that often defy description. Yet these power spiritual experiences often mark critical turning points or milestones in recovery. The importance of these of building upon these nonphysical or spiritual aspects of recovery are critical to recovery. Recovery is possible.

~ Terry Gorski  via

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April 28, 2012

Recovery – Gorski’s Developmental Model

April 28, 2012

By Terence T. Gorski, Author
May 5, 2008 –  –

 Recovery is a process of progressive growth and change.

Just as children must progress through various stages of childhood and adolescence to become adults, chemically dependent people must progress through various stages of recovery in order to achieve a meaningful and fulfilling sobriety.

The Developmental Model of Recovery (DMR) suggests a new understanding for relapse.  Just as children who try to run before they can walk tend to fall down, chemically dependent people who skip critical stages of recovery tend to relapse.  This way of understanding relapse enhances relapse prevention therapy by adding the proactive approach of identifying current growth oriented recovery tasks to the previous methods of learning to identify and manage relapse warning signs.

The Stages of the DMR The DMR consists of six progressive stages of recovery – transition, stabilization, early recovery, middle recovery, late recovery, and maintenance.  Each stage has a primary focus. During transition the primary focus is upon recognizing the addiction and developing the motivation to become abstinent.  The primary focus of stabilization is recuperation from the physical, psychological, and social damage caused by addiction.  Early recovery focuses upon identifying and changing the deeply entrenched patterns of thoughts, feelings, and behaviors that drive people back into the addiction.  Middle recovery revolves around issues related to lifestyle repair and the development of a balanced and health promoting lifestyle.  Late recovery focuses upon the resolution of family of origin issues that create pain and problems in recovery.  Maintenance is the lifelong process of growth and change needed to keep from relapsing back into the addiction.

The Stages of Recovery – Central Themes

1. Transition – Recognition of Addiction

2. Stabilization  – Recuperation
3. Early Recovery  – Changing Addictive Thoughts, Feelings, and Behaviors
4. Middle Recovery – Lifestyle Balance
5 . Late Recovery – Family of Origin Issues
6. Maintenance – Growth and Development

The DMR can be viewed as a system for prioritizing problems. It helps recovering people to answer the questions:

  • “Where should I start?”
  • “What should I do first?”
  • “What should I do next?”

The DMR is flexible. 

Having a primary focus for each stage of recovery doesn’t mean that other issues are ignored.  It means that emerging problems are dealt with in the context of the current stage of recovery. Marital problems, for example, can occur at any stage of recovery, but would be dealt with differently in the context of each stage.

  • During stabilization the marital problems would be used to mobilize a family intervention designed to motivate the addict into treatment.
  • In stabilization, a short-term “no divorce” contract would be negotiated and the couple would agree to defer in-depth work on the relationship until stabilization is complete.
  • In early recovery both the addict and their spouse would be focused upon looking at how their marital problems are a reflection of lingering patterns of addictive thoughts, feelings and actions.
  • In late recovery the marital issues would be explored as a reflection of the family of origin problems of both partners.
  • During maintenance, the issues would be explored in a developmental life stage context.

The DMR also allows the recognition of complicating factors that prevent people from successfully completing the current recovery tasks.  These complicating factors, which range from depression to severe unexpected life problems, must be dealt with in order for people to move ahead in recovery.

  • Active Addiction Active addiction is the period of time when most addicted people believe that they are social drinkers or recreational drug users who are in control.  They are getting the effect that they want from the alcohol and drug use, believe they are in control, and don’t see any problems that result from their addictive use.  By the end of this stage they recognize that they are addicted, not in control, and need to abstain from alcohol and other drugs in order solve the immediate problems created by their drinking and drug use.  This leads them into the transition stage of recovery.
  • Transition Transition begins when the addiction starts to cause problems that force the addict to make a new evaluation of the relationship between alcohol and drug use and life problems.  At the beginning of this stage most addicted people believe that they are a social drinker or a recreational drug user who is in control.  By the end of this stage they recognize that they are addicted and not in control and need to abstain.  In between these two points the addict experiences a painful inner conflict between the addictive part of themselves that wants to keep believing they are social drinkers and recreational drug users, and the sober reality-based part of them that believes they are addicted or at least on the road to addiction. There are four major tasks of transition.  The first is to develop motivating problems that force addicts to recognize that something is wrong and motivate them to take action.  Since, at this stage of recovery, most addicts don’t believe that their problems are related to alcohol or drug use, they attempt normal problem solving designed to solve the life problems caused by their addiction without dealing with the alcohol and drug use that is causing the problems. As this normal problem solving repeatedly fails, they are forced to see the relationship between alcohol and drug use. They can see that their problems are partially the result of drinking and using drugs.  They start to see that they are using too much, of the wrong kind, too frequently.  This launches most addicts into serious attempts to control chemical use by regulating how much, how often, and what kinds of chemicals they use.  Because addiction is a disease marked by loss of control, these attempts fail.  These repeated failures to control their use can cause serious demoralization that forces many addicts to accept the need for abstinence. Unfortunately, most addicts try to abstain without help and become overwhelmed by symptoms of physical and psychological withdrawal, social pressures, and an avalanche of problems that were created by their addictive use.  These problems don’t end when they stop drinking and drugging; they follow them into sobriety and make it difficult to stay in recovery. When these solo efforts at recovery fail, they realize that they cannot maintain abstinence alone and accept the need for help.  At this point many reluctantly and are often resistant to seekinf help in order to solve the immediate problems.

Tasks of Transition

1. Develop Motivating Problems:

2. Attempt Normal Problem Solving
3. Attempts At Controlled Use
4. Accept the need for abstinence
5. Accept the Need For Help

Stabilization The primary focus of stabilization is recuperation from the physical, psychological, and situational damage caused by the addiction.  During this period most recovering people have difficulty thinking clearly, managing their feelings and emotions, controlling their behavior, and coping with crisis that was caused by the addiction. The treatment during stabilization is problem oriented, directive, and immediate.  Abstinence is established and immediate crisis situations are identified.  Concrete strategies for crisis stabilization are developed, and the recovering person is closely supervised and supported in executing the strategy. The five major tasks of stabilization are recovery from withdrawal, interrupting addictive preoccupation, short term social stabilization, learning non-chemical stress management, and developing hope and motivation The first step in stabilization for many addicts is to recover from withdrawal.

There are two types of withdrawal. Acute withdrawal has short-term symptoms that clear up in three to five days and include insomnia, agitation, irritability and tremulousness.  Post-Acute withdrawal (PAW) has long-term symptoms and can require six to eighteen months to clear up.  These PAW symptoms include difficulty in thinking clearly, managing feelings and emotions, remembering things, and sleeping restfully.  At times of low stress the symptoms improve greatly. During periods of high stress the symptoms return.  If chemically dependent people experience extended periods of high stress they may develop accident proneness and severe symptoms that lead to physical or emotional collapse.

To recover from acute and post acute withdrawal requires abstinence from alcohol and other drugs, knowledge of the withdrawal symptoms and how to manage them in a sober state, proper medical management and a structured recovery program that includes education, Twelve Step Group involvement, and proper diet and exercise to aid recovery of the brain and relieve stress.  A medically supervised detoxification program may be needed if the physical symptoms or acute withdrawal become so severe the person cannot function normally.

As the withdrawal clears up, most addicts need to interrupt addictive preoccupation that is composed of euphoric recall, positive expectancy, obsession, compulsion, and craving.

  • Euphoric recall is a form of irrational thinking that focuses upon the positive memories of alcohol and drug use, while blocking out the negative memories.
  • Euphoric recall leads to the positive expectancy that chemical use may be “good for me” in the future.
  • This leads to obsession with the memories of “how good it used to be” and fantasies of “how could it be in the future.”
  • Thinking about the positive effects of alcohol and drugs can trigger an irrational compulsion to use or reactivate a physical craving.

Chemically dependent people who maintain sobriety learn to interrupt addictive preoccupation.  They analyze their past chemical use to stop the euphoric recall.  They stop thinking about how wonderful it would be to use chemicals in the future to stop the positive expectancies.  They talk openly about their obsessions, compulsions and cravings with other people who are supportive of their recovery.

As addictive preoccupation subsides, short-term social stabilization is achieved by putting a bandage on serious problems with marriages, jobs, friends, and the law.  This is not a time for permanent long-term solutions.  It is a time for emergency action to prevent future losses and buy time for recovery.

For most addicted people, alcohol and drugs are their only tools of stress management.  In order to stabilize they must learn non-chemical stress management. As chemically dependent people stabilize, they develop hope and motivation and begin to believe that recovery is possible. They can see that there is a way to get well by investing time, energy, and resources in the recovery process.

The Tasks of Stabilization

1. Recovery From Withdrawal

2. Interrupting Addictive  Preoccupation
3. Short Term Social Stabilization
4. Learning Non-chemical Stress Management
5. Developing Hope And Motivation

Now let’s turn to the stages of early recovery, middle recovery, late recovery and maintenance.

Early Recovery

During early recovery the automatic and habitual thoughts, feelings, and actions related to the addiction are identified and changed.

  • The process begins by understanding that addiction is a chronic, progressive, and eventually fatal disease that has recognizable signs and symptoms.
  • This leads to recognizing the personal symptoms of addiction and becoming convinced that “I have it!”
  • Recognition usually activates shame, guilt and nagging pain that must to be resolved on an emotional level by accepting the reality of the disease and coming to believe that it is okay to have it.
  • With acceptance comes the willingness to identify and interrupt addictive patterns of thinking, feeling, and acting (addictive TFA’s).
  • This leads to the need to learn non-addictive ways of thinking feeling and acting – in short, non-addictive ways coping with the problems of life.  We must learn to deal in a sober and responsible way with life on life’s terms in order to cope with the problems of life without the need for alcohol and drugs.  Eventually recovering people begin to challenge their fundamental values and assumptions about the need for and importance of alcohol and drug use in their lives.
  • This results in developing a sobriety centered value systemthat causes them to lose the desire to ever use alcohol and drugs.

The Tasks of Early Recovery

1. Understanding Addiction

2. Recognizing Addiction
3. Accepting Addiction
4. Identifying & Interrupting Addictive Thoughts, Feelings, and Actions
5. Learning Non-chemical Coping Skills
6. Developing A Sobriety Centered Value System

Middle Recovery The primary focus of middle recovery is on repairing lifestyle damage caused by the addiction to work, social, family, and intimate lives.  We also develop a balanced and health-promoting lifestyle by making long-standing changes in marriages, relationships with children, careers, and social lives.  Up until this time the primary focus has been on learning how to stay sober while putting band-aides on other lifestyle problems and leaving them as a second priority.

Middle recovery begins by resolving the demoralization crisis that results from becoming aware of how much work remains to be done in recovery.  At the end of early recovery the craving has been broken and a new set of sobriety-centered thoughts, feelings, behaviors, and values have been learned and internalized.  The person has a strong foundation in sobriety that will allow them to make deep and long-lasting lifestyle changes.

It is discouraging to realize that, in spite of all the hard-won internal changes, there are many critical changes in relationships and lifestyle that still need to be made.  Many recovering people become discouraged and stop their ongoing recovery process by resisting further growth.  Others have the courage to move ahead.  They are willing to confront the reality of their lives and to pay the price necessary to develop a balanced lifestyle.

The first step is repairing addiction-caused social damage by reviewing the damage their addiction has done to their families, coworkers, and friends.  They then approach each person, acknowledge their responsibility in creating these problems and offer to do whatever is necessary to fix the damage.

The next step is to build a balanced lifestyle needed to live a meaningful and fulfilling life.  This often involves changing jobs or careers, renegotiating marriages and friendships, and exploring the basics values upon which the previous lifestyle was built. When this task is complete most recovering people have a meaningful and productive job, a satisfying marriage or love relationship, a productive relationship with a number of family members and relatives, a solid twelve step recovery program with a good sponsor and numerous friends in the program, and a number of friends and associates who are not involved in the Twelve Step Program.  

The Tasks of Middle Recovery

1. Resolving The Demoralization Crisis

2. Repairing Addiction Caused Social Damage
3. Building A Balanced Lifestyle

Late Recovery

Late recovery begins when people are unable to build a comfortable and balanced lifestyle because of unfinished business from childhood.  It ends when recovering people resolve their family of origin problems and are able to approach adult living without being affected by irrational childhood beliefs.  Some people move through late recovery quickly and with little pain. For others the process is longer and more difficult because they were emotionally, physically, or sexually abused as children, or never developed adequate social skills.

  • Late recovery begins with the recognition that childhood issues are affecting the quality of recovery.  They can see that they are blindly repeating self-defeating habits that they learned as children.  They began to see that the only way out is to learn about family of origin issues by getting accurate information about how childhood experiences can affect their quality of adult sobriety.
  • The next step is the conscious examination of childhood by writing a detailed childhood history and reviewing it with a therapist, sponsor, and/or recovery group.
  • This history identifies repeating self-destructive patterns of irrational thinking, emotional mismanagement, and self-defeating behaviors that were learned as children. Knowledge of these patterns gives the power to choose to continue in self-destructive patterns or to change.
  • This knowledge must be applied to adult living in order to consciously connect what they learned as children to how they are mismanaging their lives as sober adults.


  • This leads to lifestyle change.  These deeply ingrained self-defeating habits will not disappear simply because we understand how they were developed.  We must decide to change our lifestyles, set goals, develop action plans, and enlist the help of others.

The Tasks of Late Recovery

1. Recognition That Childhood Issues Are Lowering The Quality Of Recovery

2. Learning About Family Or Origin Issues
3. The Conscious Examination Of Childhood
4. Identification of Self-defeating Patterns
5. Application To Adult Living
6. Lifestyle Change


Maintenance is a life-long process designed to prevent the tendency to relapse into old patterns of thinking, feeling, and acting that can set the stage for a relapse to addictive use.

  • The first task of maintenance is maintaining a recovery program that promotes prompt identification and management of problems.
  • Next is a policy of effective day-to-day coping. People in maintenance are not free from problems, but they have learned how to manage problems efficiently without having to resort to alcohol or drugs.  One AA member put it this way.  “I measure my recovery not by how many problems I have, but by how well I manage the problems that I do have.”
  • The next task is continued growth and development.  The human mind, when free from alcohol or drugs, is designed to seek truth.  Human beings continue to grow and change from the time we are conceived until the time we die.  We are not free to choose whether we grow and change, we are only free to choose the direction of that growth and change. Addiction creates the innate tendency to grow in negative and self-destructive ways.  For most recovering people positive growth and change requires constant attention to the details of life and living.

Staying sober for a lifetime requires effective coping with life transitions and complicating factors.  All people move through different periods of adult development that present different problems and challenges.  In late recovery, people develop a sense of what normal adult development is all about and anticipate the changes they will undergo, as they grow older.  They learn to accept each progressive stage of maturity with a sense of serenity. They surrender gracefully the ways of youth while embracing the ways of maturity.

The Tasks of Maintenance

1. Maintaining A Recovery Program

2. Effective Day-to-Day Coping
3. Continued Growth And Development
4. Coping With Life Transitions And Complicating Factors

Using The DMR

The DMR is a flexible tool that can be used in a variety of ways.  Counselors can learn to help clients evaluate their stage of recovery and establish treatment plans.  The DMR can also form the basis of a powerful self-care technology that can enhance, but not replace, the working of the Twelve Steps.  By learning about the stage and tasks of the DMR, many recovering people can develop effective recovery plans and make better decisions about what type of professional help is needed.  The DMR is a powerful tool that is needed to move the changing field of chemical dependency treatment into the future. For more information please contact the CENAPS office at 352-596-8000 or visit CENAPS. Publications for RPT are available at or 1-800-767-8181.

Stress Self-Monitoring and Relapse

April 27, 2012

By Terence T. Gorski 

An exciting new development in the treatment of addiction is the integration of stress management into the treatment and recovery process.  Although stress management has been recognized as an important adjunct to addiction treatment for over twenty years, the relationship between acute stress reactions, denial and treatment resistance is now becoming clear.  As stress goes up, so does denial and treatment resistance.  A key to effectively managing denial and treatment resistance is to teach recovering people to recognize their stress levels and use immediate relaxation techniques to lower their stress.

Recovering people are especially vulnerable to stress.  There is a growing body of evidence that many addicted people have brain chemistry imbalances that predispose them to both addiction and difficulty in managing stress.  The regular and heavy use of alcohol and other drugs can cause toxic effects to the brain that create symptoms that cause additional stress and interfere with effective stress management.

Many recovering people have severe problems with Post Acute Withdrawal (PAW).  PAW is caused by brain chemistry imbalances that are related to addiction that disrupt the ability to think clearly, manage feelings and emotions, manage stress, and self-regulate behavior.  PAW is stress sensitive.  As the level of stress goes up, the severity of PAW symptoms increases.  As PAW symptoms get worse, recovering people start losing their ability to effectively manage their stress.  As a result they are locked into chronic states of high stress that cause them to vacillate between emotional numbness and emotional overreaction.

According to the National Institute on Drug Abuse, exposure to stress is one of the most powerful triggers for relapse to substance abuse in addicted individuals, even after long periods of abstinence.  Stress can cause a problem drinker to drink more, and a recovering alcoholic to relapse.

Many counselors are dealing with these stress related problems by using a simple tool called The Stress Thermometer.

The Stress Thermometer

The Stress Thermometer is a self-monitoring tool that teaches people to become aware of their current stress levels, notice increases and decreases in stress during sessions, and encourages the use of immediate relaxation techniques to lower stress as soon a stress levels begin to rise.  The stress thermometer makes the problem of stress an acceptable issue to bring up any time stress levels increase to a point where denial and resistance are activated.

The concept of using a stress thermometer came from thinking about how we use a temperature thermometer to measure our body temperature.  When we take our body temperature we use a thermometer to tell us accurately and objectively what our body temperature is.  When we use a stress thermometer, we use a system for self-monitoring our stress levels that can tell us accurately and objectively how high our stress levels are.

The stress thermometer is divided into four color-coded regions: blue – relaxation, green – functional, yellow – acute stress reaction, and red – trauma reaction.

Relaxation: Stress levels of 1, 2, and 3 are coded blue. Blue is a color that represents a state of relaxation. We are relaxed and attending to the completion of any tasks. Stress Level 1: Relaxed Nearly Asleep; Stress Level 2: Relaxed – Not Focused; and Stress Level 3: Relaxed – Focused

Functional Stress: Stress levels 4, 5 & 6 designate the zone of functional stress. They are coded green because green is a color that represents “go”.  At stress levels 4, 5, and 6 we are experiencing stress levels that are high enough to give us the energy we need to get things done but are not so high that the stress begins to impair our performance.  Stress Level 4: Focused and Active; Stress Level 5: Free Flow With No Effort; and Stress Level 6: Free Flow With Effort.

Acute Stress Reaction: Stress level 7, 8, and 9 are coded yellow. The color yellow represents caution. At stress levels 7, 8, and 9 we are experiencing an acute stress reaction. The word acute means immediate and severe. Our immediate levels of stress have gotten so high that we can’t consistently function normally. We’re in danger. Stress Level 7: Space Out; Stress Level 8: Get Defensive; and Stress Level 9: Overreact.

Traunatic Stress: Level 10 Plus

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