Personal Reflections On Its Development and Evolution
By Terence T. Gorski,
September 24, 2008
It was a cold Friday night on the near north side of Chicago. It was late September of 1970. I remember that night clearly. I was huddled down over a cup of coffee in a greasy-spoon restaurant on the corner of Clark Street and Webster Avenue. I was 20 years old and talking with my best friend, Joe Troiani.
We were both working as psychiatric assistants at Grant Hospital of Chicago and taking intensive training in addiction psychotherapy from Richard Weedman, the director of the hospital’s Alcoholism Treatment Program (ATP). The training was working. My emotions were stirred up. My motivation was high. My mind was working in a state of creative overdrive.
As I sat there, I realized that the past year of clinical training had changed me. The combination of classroom training and practical experiences in the real-world of treatment was a powerful brew. I had the chance to test out the ideas I was learning in the classroom with the patients I was working with. The relationships that I built with recovering patients and the members of the multidisciplinary staff had led me into a new world. I was just beginning to explore that world and learn how to talk about it with trusted friends.
Pieces of new knowledge and systems for personal growth were clashing in my mind. I was struggling to organize what I was learning. Three different bodies of knowledge were in competition.
- The first body of knowledge was the gestalt and humanist therapy methods I was learning from my psychology professor Dr. Stan Martindale. Stan was a former student of Carl Rogers.
- The second body of knowledge was from Richard Weedman, my program director, clinical supervisor, mentor, and my instructor in the intensive addiction psychotherapy program I was involved in. This training involved three hours of classroom instruction each week followed by thirty-hours of working with addiction and psychiatric patients on the inpatient unit between classes.
I didn’t know it then, but Mr. Weedman would go on to draft the first standards for the Joint Commission for the Accreditation of Hospitals (JCAH). By doing so he shaped the history of addiction treatment.
This clearly demonstrated to me that the words of President John F. Kennedy were true. “One person can make a difference,” Kennedy said. “Every person should try.”
- The third body of knowledge was from Jim Kelleher, who provided me with direct day-to-day supervision on the unit. Jim was a recovering alcoholic with long-term sobriety. He was the first to bring AA meetings and sympathetic treatment services to the gay community on the near north side of Chicago. He gave me very practical and no-nonsense suggestions for how to integrate, within my own mind and behavior, the models of psychotherapy with Twelve Step Recovery.
Grant hospital was unique from other treatment programs using the Minnesota Model. Grant Hospital integrated the emerging cognitive and emotional psychotherapy technique with the most advanced understanding of alcoholism as a physical disease. All of this had to fit together with the principles underlying the 12-Steps.
I could sense the value of all three perspectives, but something was missing. I needed a higher perspective – a bigger frame of reference that could organize this information into a practical system. I knew a lot, but I was struggling to figure out how to apply what I was learning in the real world of treatment and recovery.
On that cold night in September of 1970, a vision of how to do this came together in my mind. This was a moment of clarity – a peak experience that Fritz Pearls called “the Aha moment” and many people in Twelve Step Programs call “a blinding flash of the obvious” or “a spiritual awakening.”
I didn’t know it at that time but this was the inception, the point of origin, of a personal sense of knowing that I had something new to contribute to the field of Alcoholism Treatment. It was a turning point in my thinking and in my sense of professional self-esteem. It was almost a mystical experience. Let’s take the almost out of that statement. It was a mystical experience.
I could see somehow in my mind a vision or an image of how all these different models and approaches needed to be brought together. The solution to building this higher order model was common language. Somehow we needed to translate both the psychological jargon and 12-Step jargon both into plain English so they could be understood and compared. That would allow the development of simple sets of instructions for completing self-application.
As I struggled to explain this vision to Joe, I found myself at a loss for words. The vision was general and I had no words to explain the sense of knowing that seemed to have reorganized the very circuits of my brain. But the vision was there. From that moment on, I didn’t have the vision – the vision had me. I didn’t know it then, but this vision would shape the rest of my professional career and personal life.
At first the vision was poorly articulated. It was a sense of how to build a containing framework that would allow the information and skills I was learning to come together in a practical and effective way for use with the patients I was working with. It was the idea of building a higher order model of addiction treatment.
This model, which would slowly evolve into The CENAPS® Model of Recovery & Relapse Prevention, would have to be big enough to include and integrate the major therapeutic approaches to addiction. The vision was to create an effective and easy to use system that integrated the physical, psychological, social, and spiritual aspects of recovery. Most importantly, the model needed to be a living, growing, and evolving system capable of integrating new research information as it became available. Many years later, the term biopsychosocial would come into use. That word and the ideas it represented were no available to me. So I began calling it the Biological Behavior Dynamic (BBD) which involved three related categories of ideas:
- Biological, which included the application of neuropsychology and brain science show how the brain was effected by addiction;
- Psychological, which described how the brain changes affected the nonphysical aspects of the mind. I conceptualized the psychological systems as being dynamic interaction among thoughts (T), feelings (F), urges (U), and actions (A). Behavior, in the context of this model, was defined as an urge action combination.
- Behavioral described how we acted that could be observed or directly impacted the world around us. It included what we did, which included what we said in words, and communicated verbally and non-verbally. It also included how these things effected out relationships with people, social systems, and the physical world of things.
- The term “dynamic” was meant to describe the constant and nearly instantaneous interaction between and among these systems.
Latter, when I heard and read about the term biopsychosocial I quickly abandoned the original idea of the BBD and found that the biopsychosocial model was a better way to describe the same basic ideas.
To bring this vision into reality, the model needed a simple and no-nonsense language. It needed to avoid using psychological jargon, which I dubbed psycho-babble. It also needed to avoid the reliance on 12-Step slogans and platitudes, which I dubbed recovery-talk. My goal was to express all of the ideas and the principles underneath the psycho-babble and recovery-talk in plain English that anyone could understand. I called this no-nonsense language – plain English.
This no-nonsense language, however, would need to maintain a clear focus on the core issues of what addiction is and how to recover and avoid relapse. It would need to clearly describe practical methods that could work in the real world.
As a result of this conversation with a trusted friend on a cold night in September of 1970, I developed the conviction that such a system could be developed and taught to both therapists and recovering people. I was convinced that it could include the rich and effective therapeutic systems that had evolved over time, while transcending their limitations. I knew this system could open up a bigger frame of reference that would provide new and more effective approaches to recovery and relapse prevention.
Many years latter, a book by Ken Wilber gave me the precise words to describe what the model needed to do. These words were: Include and Transcend. Include the old ideas and methods that had stood the test of times, but put these ideas into a bigger frame of reference that would allow them to transcend or move beyond the original limitations in thinking.
Although the vision was vividly clear in my own mind, describing it and developing the supportive materials became a life-long work. As I began using these new ideas with clients, the system took on greater clarity. Concrete recovery exercises were developed that evolved into a flexible system of manualized treatment.
The description of this system emerged from the training sessions that I conducted with both recovering people and multidisciplinary treatment professionals. Since the training sessions were skill oriented and experiential I usually learned as much from the students as they did from me.
Each time I did a training workshop, I was able to integrated new research, knowledge and experiences I had gathered since the last experience. It meant hours of preparation and hours of debriefing and reviewing what happened in the training sessions.
The training was designed to help participants to connect their real lived experiences, both professionally and personally, to the practical methods of recovery and relapse prevention that were part of the emerging CENAPS® Model. The responses were usually positive, and most people attending the advanced skills training sessions started adapting and using various parts of the model into their work with addicts. They reported that they saw dramatic changes in how their clients responded to treatment and recovery.
The agendas grew into training handouts. These in turn grew into training manuals. The manuals grew into books. All of these things both expanded and simplified the model. Over time The CENAPS® Model focused on the critical path of recovery. It shrugged off a lot interesting but unnecessary information and recovery tasks that could sidetrack the treatment and recovery process.
Over the years I have published many books and articles describing aspects of the CENAPS® Model. Looking through this catalogue and our website www.relapse.org you can see the wealth of information that has been made available. In recent years some, but not a lot, of these publications have gone out of print. There has always been one vital publication that has been missing – a concise overview of the entire CENAPS® Model.
I have been working on this description for years, yet I never felt the model was complete. I viewed it as a work in progress, and I still do. So I was reluctant to commit myself to a publishing an overall description that I knew would grow and change as more research and experience became available.
Recently I was persuaded by my colleagues that a decisive overview of the entire model was necessary. I was convinced that many people are using a small piece of the CENAPS® Model and are not even aware that other components of the model exist.
As a result, I am publishing a comprehensive overview of the CENAPS® Model. This is meant to provide an overview of the entire system and how the different parts of the system work together.
Here is a general overview: The GORSKI- CENAPS® Model consists of three primary theoretical models, built upon a solid foundation of research. These are:
(1) The Biopsychosocial Model of Addiction
(2) The Development Model of Recovery, and
(3) The Relapse Prevention Model.
The Biopsychosocial Model of Addiction is based upon an integration of four science-based models of addiction:
(1) The Neuropsychological Predisposition Model,
(2) The Neuropsychological Response Model
(3) The Social Learning Model, and
(4) The Cognitive Therapy Model of Substance Abuse.
The components of these models have been translated into simple language and carefully integrated for consistency.
The Developmental Model of Recovery (DMR) (DMR) was initially developed from the observations of client’s recovery over the course of two years of outpatient substance abuse treatment. This model was first published as the chapter of a recovery education book in 1982 (Miller et al 1982). It was then published as a training manual in 1985 (Gorski 1985), and latter by Hazelden in 1989 (Gorski 1989).
The Developmental Model of Recovery used in the GORSKI-CENAPS® Model is consistent with the Stages of Change Model developed by Prochaska and DiClemente (Prochaska and DiClemente 1994) and the Developmental Model of Recovery developed by Stephanie Brown (Brown 1985).
The Relapse Prevention Model is consistent with the original cognitive model of relapse prevention (Marlatt & Gordon 1988), state-of-the-art relapse prevention methods described in the Comprehensive Textbook of Substance Abuse (Daley & Marlatt 1997) Relapse Prevention has been demonstrated to be effective by a number of research studies.
What evolved was a system of Manualized Treatment in the form of recovery workbooks. Research suggests that the most effective treatment programs utilize a manualized clinical system that includes reading assignments, journal assignments, self-assessment questionnaires, and preparation assignments for group and individual therapy sessions.
The primary focus of all sessions is to guide the patient in the completion of structured exercises contained in a recovery workbook. Workbooks are available for Cognitive Restructuring for Addiction, Denial Management Counseling, Relapse Prevention Counseling (Practical Exercises for Managing High-Risk Situations), Relapse Prevention Therapy (Managing Core Personality and Lifestyle Issues), Addiction-Free Pain Management, Recovery and Relapse Prevention for Food Addiction, and others. A process has been developed for customize the design of treatment manuals that address specific recurrent issues within treatment programs.
All applications of the GORSKI-CENAPS® Model rely on the use of core clinical processes directed at teaching clients specific recovery skills. The basic recovery skills that are adapted to each level of a patient’s recovery are:
1. Introspection Skills which include the ability to identify self-talk, feelings and emotions, and urges to act.
2. Social Awareness Skills which include The ability to observe and accurately assess the behavior of others.
3. Cognitive Skills which include the ability to identify and challenge addictive and irrational forms of thinking.
4. Affective Skills which include the ability to recognize feelings and emotions, accurately describing them in words, and communicated them to others when appropriate.
5. Behavioral Skills which include impulse control and self motivation. Impulse control is the ability to recognize cravings and self-destructive urges and to stop acting out on those cravings or urges. Self-motivation is the ability to force yourself to engage in healthy and productive behavior even when you don’t want to.
6. Social Skills which include relationship building models based upon guiding clients to slowly rebuild their social network centered around sober and responsible activities rather than addictive and irresponsible ones. The core social skills include: the ability to engage in productive communication using an active listening model, the ability to set and enforce appropriate boundaries and limits in social situations, the ability to stop using controlling and manipulative behaviors, and the ability to engage in negotiation and conflict resolution.
7. Problem & Warning Sign Identification, which include the ability to identify and develop a personalized list of the unique personal problems that lead people from stable recovery back to the use of alcohol, drugs or self-defeating behaviors. These problems are called relapse warning signs.
8. Problem or Warning Sign Management Strategies, which consist of concrete situational and behavioral coping skills for managing the warning signs without returning to addiction or other self-defeating behaviors.
9. Recovery Program Development, which include instruction in how to develop a schedule of recovery activities, which provides a regular daily structure for maintaining a healthy and sober lifestyle. Any break in the structure of the recovery program also is viewed as critical relapse warning sign and immediate steps to intervene upon the impending relapse are taken
I am excited about publishing the comprehensive overview of the entire system. The CENAPS® Model is also being expanded to address related mental health problems including Depression, Suicide, and Antisocial Behaviors.
It is exciting for me to look back over my career and see a vision of a recovery system become a reality that is helping people in the United States, Iceland, England, Denmark and many other countries around the world. I will continue devoting my energies to the refinement of the CENAPS® Model and its systematic application to a broad spectrum of behavioral health and societal problems. I hope you will enjoy and benefit from an understanding how the model developed and my memories of key turning points in its development. I hope that this understanding will help you to take ownership of the model and use it more effectively.
Bandura, Albert, Social Learning Theory, General Learning Corporation, 1971
Brown, Stephanie, Treating the Alcoholic: A Development Model of Recovery. New York, John Wiley & Sons, 1985. ON THE INTERNET: http://www.amazon.com/Treating-Alcoholic-Developmental-Model-Recovery/dp/0471161632
Daley, Dennis C. and Marlatt, G. Alan, Relapse Prevention; IN EDS: Lowinson, Joyce H., Ruiz, Pedro, Millman, Robert B., and Langrod, John G., Substance Abuse: A Comprehensive Textbook, Williams & Wilkins, Baltimore 1997
Gorski, Terence T., The Developmental Model of Recovery: A Workshop Manual. The CENAPS Corporation, Hazel Crest, Illinois, 1985.
Gorski, Terence T., Passages Through Recovery: An Action Plan for Preventing Relapse, Hazelden, 1989
Marlatt, G. A. and Gordon, J. R., Eds. (1988) Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behavior. New York: Guilford Press
Miller, Merlene, Gorski, Terence T., and Miller, David K., Learning to Live Again: A Guide to Recovery from Alcoholism. Independence, Missouri, Independence Press, 1982, pp. 123-128 ON THE INTERNET: http://www.amazon.com/Learning-Live-Again-Merlene-Miller/dp/0830903720
Prochaska, James O., Norcross, John C., & DiClemente, Carlo C., Changing for Good, William Morrow and Company Inc., New York, 1994
Note: I kept the original publication date because I have made so few changes.
I am reviewing this article and moving it from my hard drive to my blogs on 2013-12-19.