Include and Transcend: An Evolutionary Clinical Model

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By Terence T. Gorski, Author

The goal of devoloping a clinical model that will stand the test if time is to clearly define its core clinical principles in a way that encourages new and creative ways to bring those principles to life in the real world of clinical practice.

THE GORSKI-CENAPS Model has stood the test of time because it includes a broad foundation of evidence-based core principles and practices and organizes them in a way that transcends old and more limiting principles and practices. In this blog, I want to explore the clinical models that have been integrated and systematically applied to the treatment of addiction.

The Theoretical Models

There are three primary theoretical models upon which the GORSKI-CENAPS model is constructed. These are: 

  • The Biopsychosocial Model of Substance Use Disorders, 
  • The Development Model of Recovery, and 
  • The Relapse Prevention Model. 

 Each of these components is built upon a solid foundation of research studies.
The Biopsychosocial Model 

 The Biopsychosocial Model of Addiction is based upon an integration of four science-based models of addiction: 

  • Neuropsychological Predisposition Model;
  • Neuropsychological Response Model;
  • The Social Learning Model; and 
  • The Cognitive Therapy Model of Substance Abuse. 

 The components of these models have been translated into simple language and carefully integrated for consistency. The basic research-based components of these models will be briefly explained so their application with the GORSKI-CENAPS Model can be easily recognized.
1. Neuropsychological Predisposition Model[2]: 

 The Neuropsychological Predisposition Model describes the preexisting brain and central nervous system problems that increase the risk of becoming addicted. These predisposing neuropsychological risk factors may be related to genetically inherited traits, brain dysfunction caused by improper prenatal care, the effects of prenatal alcohol or drug use, physical neglect (the absence of touching, rocking, and responsive loving human interaction) or abuse in early infancy, severe psychological trauma experienced at different points in childhood and adolescent development.

These preexisting neuropsychological problems make people more vulnerable or susceptible to abuse and addiction to alcohol and other drugs and make them susceptible (i.e. less resistant) to the damaging effects of alcohol and drugs to the brain. These preexisting problems are usually exacerbated by alcohol and drug use and interfere with efforts to stop drinking and using drugs.

These predisposing neuropsychological problems are:

  1.  The tendency to have severe mood swings, 
  2. Fifficulty in concentrating, 
  3. Difficulty persisting in tasks through completion, 
  4. Impulse control problems, 
  5. The tendency to be hyperactive and irritable, and 
  6. Cognitive impairments that interfere with self-awareness, awareness of the immediate environment, abstract reasoning, problem solving, learning from past experiences, and the logical consequences of current behavior to anticipate and avoid future problems.

The early research basis of this neurobehavioral model was the analysis of 139 supportive scientific studies (Tarter et al 1988) [3]

2. Neuropsychological Response Model of Addiction[4]: 

The Neuropsychological Response Model describes the primary reactions of the brain and nervous system to the ingestion of alcohol and drugs that motivate people to keep using in progressively greater amounts and to have difficulty stopping even after serious problems develop.

People start drinking and using drugs as a result of personal curiosity motivated by social pressure to use alcohol or drugs and the availability of these substances.

Neurobiological Reinforcement: People at high risk of addiction experience neurobiological reinforcement when they use alcohol or other drugs because the substances activate brain chemistry responses that cause a state of euphoria that is experienced as a unique sense of pleasure and well being. This feeling of euphoria acts as a positive reinforcement that motivates people to keep using alcohol or other drugs.

Tolerance: People at high risk of addiction develop tolerance when they start using alcohol and other drugs regularly and heavily. Tolerance occurs as neurochemical processes in the brain adapt to the presence of alcohol and drugs in a way that allows people to feel and function normally when using. This means they need to use progressively larger amounts of alcohol and drugs In order to experience the desired euphoric response. The combination of neurobiological reinforcement and tolerance motivates people to use progressively larger amounts of alcohol and drugs more and more frequently.

Physical Dependence: When people at high risk of addiction use alcohol and drugs frequently and heavily they develop physical dependence. This is because their brain requires certain amounts of alcohol or drugs to function normally. If the amount of alcohol and drugs needed for normal functioning is not provided, they experience withdrawal symptoms caused by brain chemistry imbalances that make it difficult to function normally and creates a state of emotional distress. There are two distinct withdrawal syndromes: acute withdrawal which occurs immediately after the cessation of alcohol and drug use; and post acute withdrawal which persists for a prolonged period of time after the cessation of alcohol and drug use. Alcohol and drug withdrawal motivates people to start using alcohol and drugs when they try to stop. Acute withdrawal produces immediate and severe symptoms prompting a return to substance use within hours or days of attempting to stop. Post acute withdrawal produces a chronic state of low grade agitated depression accompanied by difficulty in thinking clearly, a tendency to swing between episodes of emotional overreaction and emotional numbness, difficulties with impulse control, and problems with self-motivation. These symptoms become more severe during periods of high stress. Post Acute Withdrawal motivates people to start using alcohol and drugs during periods of high stress after the acute withdrawal has subsided.

Progressive Brain Dysfunction: People who become addicted develop progressive brain dysfunction that can become so severe that it meets the criteria of a substance-induced organic mental disorder. This severe brain dysfunction creates an inability to meet major life responsibilities and in its severe form disrupts the ability to perform normal acts of daily living.

The early research basis of this neurobiological model was the analysis of 160 supportive scientific studies (Tabakoff & Hoffman 1988) [5]

Social Learning Model: The social learning model is based upon extensive evidence that the development of addiction to alcohol and other drugs is related to a complex interaction among a variety of personal, interpersonal, and environmental factors that motivate people to use alcohol and drugs to cope with a wide variety of experiences. These factors and their relationship can be summarized as follows:

Vicarious Learning: People learn a set of self-regulatory responses to alcohol and drugs by observing people and events around them. These self-regulatory responses are initially learned in childhood and are either reinforced or challenged as a result of critical developmental and other life experiences. These self-regulatory responses include:

  • Beliefs about alcohol and drug use
  • Behavioral skills for acquiring and using alcohol and drugs
  • Self-monitoring skills for observing drinking and drugging behavior
  • Judgmental skills for evaluating the benefits and disadvantages associated with alcohol and drug use,
  • Self-rewarding behaviors that are used when their alcohol and drug use conforms with their beliefs and values
  • Self-punishing behaviors that are used when their alcohol and drug use does not conform to their beliefs and coping skills for dealing with the consequences of alcohol and drug use.


Personal Experience with Alcohol and Drug Use:
The person has initial experiences with alcohol and drugs, uses the learned self-regulatory responses, and develops a set of positive memories associated with alcohol and drug use.

Positive Expectancy: The person develops the belief that the use of alcohol and drugs will produce positive or reinforcing outcomes and comes to anticipate and expect these outcomes.

Conditioned Craving: Specific experiences or sensory triggers become associated with the reinforcing effects of alcohol and drugs and when experienced they activate a craving or urge to use alcohol and drugs.

Adaptation of Self-regulatory Processes: The people slowly adapt their self-regulatory responses in order to maximize positive reinforcement and minimize negative reinforcement. This involves the development of distorted perceptions and irrational ways of thinking that support a positive belief about alcohol and drug use in spite of the presence of progressive, more severe adverse consequences.

Self-Reinforcing Addiction Cycle: The development of a self-reinforcing addiction cycle that locks the person into a pattern of progressively more dysfunctional cognitions and behaviors.

The early research basis of this social learning model was the analysis of 111 supportive scientific studies (Wilson 1988) [6]

Cognitive Therapy of Substance Abuse: The GORSKI-CENAPS® Model is fully consistent with cognitive therapy principles for substance abuse treatment (Beck et al 1993[7]; Ellis et al 1988[8] ). The Cognitive Model of substance abuse is based upon the observation that substance abusers develop a set of irrational beliefs that support their ongoing use of alcohol and drugs while blocking out or minimizing the importance of problems caused by their use. Treatment is based upon establishing a collaborative relationship with the client and helping them to identify and challenge these basic addictive beliefs.

Aaron Beck provides 239 scientific references that support the Cognitive Therapy Model of Substance Abuse Treatment. Albert Ellis provides 139 scientific references that support the application of Rational Emotive Therapy (RET) to the treatment of substance abusers.

The features of these four models were translated into common language and integrated into general framework of the earlier phenomenologically developed Model to provide the basic form and structure of the current GORSKI-CENAPS® Model. The model was later updated to assure it’s consistency with a more recent biopsychosocial analysis of addiction.

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