PTSD and Addiction: A Cognitive Restructuring Approach

January 11, 2014
By Terence T. Gorski, Author
June 22, 2013

Recovery Is Possible With
Cognitive Restructuring

 WHEN  TREATING PTSD AND ADDICTION, I don’t use a single approach – I use a consistent set of principles and practices. I strive to be sensitive and adaptive to the emerging needs of patients in the moment. The key seems to be a balance of flexibility and consistency.  Everyone responds in a uniquely personal way in learning to understand and manage PTSD. I like the idea that and the PTSD recovery process results in Post Traumatic Growth. People don’t just overcome their symptoms. They grow and change in positive ways.


First I do a comprehensive assessment of PTSD. This includes an analysis of presenting problems, a life history, and a history of treatment and recovery. I include efforts at self-help to be important. Most people try everything they know to get a handle on their PTSD before seeking any formal or professional help.


If the assessment provides confirmation of active PTSD symptoms, I do a comprehensive addiction assessment because addiction is so common in patients with PTSD. If the addiction is not identified and treated concurrently, the PTSD treatment can make the addiction symptoms worse, and the addiction symptoms can prevent patients from benefiting from the treatment/recovery of PTSD.


Then I use psycho-education to give people a new cognitive frame of reference about PTSD. This is extremely important because, although most people are familiar with the general idea of PTSD, most lack accurate information or a useful way of understanding the symptoms and the pathways to recovery.


The most important thing I want to teach is that patients are trauma survivors, not trauma victims. I also want to be sure that the trauma is over. You work differently with PTSD if the trauma is still ongoing It makes a difference if: a soldier needs to return to combat or is home from the war; if a battered child is still living under the control of violent parent and will have to go home; if the abused spouse is out of the marriage or still involved due to children or financial issues; if the person is in prison and going back to the cell block or if they have been released. If they are actively involved in an ongoing trauma teach survival and coping skills, safety plans, and ways to responsible get out and get safe.


The first goal is to provide relief for the most painful mediate symptoms. This often involves referral for EMDR. I am not skilled with this method, but many patients find it helpful. This also involves basic training in relaxation, diet, and exercise as a part of overall stress management.


Then I do a guided life and symptom history so people can see how symptoms have affected their life negatively through pain, problems, and losses; and positively through a process of making decisions that lead to positive change, growth, and development. This is a positive psychology intervention called Post Traumatic Growth (PSG).


I develop a comprehensive list of the PTSD symptoms that patients are struggling with. This often involves showing them a list of symptoms because they lack the words or language to describe what they are experiencing. It is easy for me to forget how important it is to give patients a language of recovery so they can identify and communicate their experiences.

Once I have a comprehensive symptom list, I ask patients to evaluate the frequency (how often) and severity (how disruptive) the symptoms tend to be.  Then explore each symptom. First I want them to tell me real-life stories about what happened when they experienced each symptoms. I like to get at least two stories about each – one story in which they managed it pretty well, and one story in which they managed it poorly. This helps them to take ownership of their symptoms and get a feel for the new language they are learning. I get stress enough how important I feel this process by relating symptoms to actual lived experiences is for most patients.

I look for patterns of symptoms. Many symptoms appear in clusters that are activated by the same trigger event and once they appear, they mutual reinforce and intensify each other. I treat these symptom clusters as a single symptom and help patients to find a meaningful name it.


I make it a point to discuss how patients have managed to survive up to this point. I want to find periods of time when they have successfully managed their symptoms or been symptoms free. What were they doing at those times. What was going on or not going in their lives. What thoughts, feelings, behaviors, and social styles are associated with successfully coping with the symptoms?


I also like to introduce the concept of PTSD symptoms episodes – moments in time when the symptoms get turned on by triggers and turned off by things like rest and safe environments. The idea is that the symptoms are not always there. Most patients believe that they are, but they are usually wrong. The symptoms are usually turned on some of the time and turned off at other times. Once a symptoms episode is activated by a trigger, it starts, runs a cycle, and then ends or significantly diminishes in intensity. Know that it will end gives strength in facing the symptoms. Naming the symptoms identifies the enemies or the monsters to be dealt with. At the very least, at some times the symptoms are less severe and more manageable than at other times.


I encourage patients to do conscious self-monitoring o their symptoms at least four times per day (breakfast, lunch, dinner, and before bed) and note the specific symptoms experienced, how severe the symptom is, what is happening that is making it more severe, and what could be done to make it a little bit less severe. This starts patients on a journey of Post Traumatic Growth by showing them they are not totally at the mercy of these symptoms — that they can choose to do things to make their symptoms a little bit better or a little worse.


I find that many patients are fearful of the flashback and dissociative states that they get into that are often a part of PTSD. They fear that if they get into these states they will fall into a bottomless black pit and never be able to crawl out again. This is why a believe so many people are afraid to start talking about past experiences or the triggers that activate symptoms. They are afraid that once the symptoms start they won’t stop.


To counter this, I like to have patients find a safe-memory or fantasy that they can go to and practice going there when they are feeling pretty good. I want them to learn and practice relaxation exercises that work for them. I give them a smorgasbord of relaxation methods to choose from. Giving choices, it seems, reduces resistance. I also avoid “one size fits all” methods of relaxation — but no methods really do work for everyone. I avoid using guided imagery at first because I find it unpredictable. Once patients relax and engage their imagery processes, they often are vulnerable to intrusive thoughts, feelings, and flashbacks.


I like to teach centering, deep-breathing, and mindful (detached) awareness, I want to be sure that patients learn how to get back into the here and now and stop intrusive symptoms as soon as they start.

I avoid what I call “big bang catharsis techniques” which take the patients quickly into deeply re-experiencing the memories of trauma. I have just had too many b ad experiences with patients regressing and getting worse as a result of these techniques. I personally don’t find using them worth the risk.

I would rather take patients into the memories as they emerge in the assessment and recovery skills training process. I want to be sure that patients have the ability to stop and crawl out of the experience and get back into a tight anchor with here-and-now-reality.


I also focus on building support networks of people, places, and things that can be used when things get tough. Simple things like: Who can you call if you need to talk? Who should you avoid if your symptoms are bad in the moment? What can you do that will help? What should you avoid doing because it will make things worse? I am especially concerned about having a support systems that can be used during the night. This is when the symptoms tend to be more intense and the support less available.


The general structure I wrap these general principles of cognitive restructuring. I use the word cognitive to mean total information processing with the brain and the mind. This involves Thoughts (T), Feelings (F), Urges (U), actions (A), and relationships. It also involves subtle intuitions and openness to spiritual experiences which seem to be very common in people who survive trauma. using a cognitive restructuring process. I ask patients to complete these sentence stems, or I turn them into open-ended questions. Using active listing is critical. Patients must feel listened to, understood, taken seriously and affirmed as a person. This process turns a sterile and “objective” assessment into a highly personalized and collaborative self-assessment.


Here is a general structure for the process:

1.  The symptom that I am experiencing is …

2.  When I experience this symptom I tend to think …

  • A more helpful way of thinking might be ….

3.   When I experience this symptom I tend to feel …

  • A more helpful way of managing those feelings might be ….

4.  When I experience this symptom I tend to manage it by doing the following things …

  • A more helpful behavioral strategy for managing this symptom might be ….

5.  When I experience this symptom what I do to try to get help from other important people in my life is …

  • A more helpful strategy for getting the help and support if others in managing this symptom might be ….

6.   he overall daily plan I have for managing my PTSD recovery is …

  • Some ways of making my recovery plan more helpful for me might be …


This is a simplistic skeleton of the basic principles and practices of a cognitive restructuring approach for PTSD. This sketch, of course, just covers some of the steps on the critical path to recovery and relapse prevention. It also presents my preferences as a therapist based upon my past experiences with clients. I am sharing this as a personal report on lessons learned.

 Gorski Books

The New Opiate Addict

January 11, 2014

By Terence T. Gorski, Author
January 11, 2014


Men Get Addicted

A Profile of the New Opiate Addict

There is an old stereotype of opiate addicts painting them as old-school street junkies who over-dose in alleys with needles in their arms. This stereotype is not only wrong – it is dangerous. It deters people from recognizing the new opiates, especially prescription pain-killers and their non-medical use, and the new opiate addicts who are thirty-something in age, largely employed even in this faltering economy, and spending one-third of their annual income of about $53,000 per year supporting their opiate addiction.


Siobhan A. Morse, Researcher

I developed this snapshot of the new opiate addict from a research study by Siobhan A. Morse who is the Director of Research for Foundations Recovery Network

Detailed Information On The New Opiate Addict

Here is a summary of the data upon which this profile of the new opiate addict is based: Of the 1,972 patients who agreed to participate in research between January 2008 and June 2010:

– 49.8% reported opiate use within the 30 days prior to admission:

– 11.8% reported heroin use,

– 5.4% reported non-medical use of methadone, and


Women Get Addicted

– 32.4% reported using “other opiates,” which includes nonmedical prescription opiate use.

– 8.4% of the opiate users reported using more than one type of opiate.

– The average age was 32.5 years, 59% were males and 49% were females.

– Over half (52%) reported being employed in the 30 days prior to admission; however, they also reported only working an average of 10.7 days.

– 95.8% reported receiving money from illegal activity in the month prior to treatment.

– Their average monthly income was $1,465 in the month prior, earning about $53,000 per year.

– Most spent an average of 35% of their earned monthly income on opiate drugs.

– Six months post-treatment, 73.2% of opiate users remained alcohol-free and 80.5% of were drug-free.

Opiate Use Fact Sheet

– There was a 400% increase in prescription painkillers from 1999 to 2010 (National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 2012).

– In 2011, prescription painkillers are the largest single category of illicit drug use other than marijuana (Substance Abuse and Mental Health Services Administration, 2012).

– The USA and Canada combined account for 6%, 22 tons, of the world’s heroin consumption in 2010 (United Nations Office on Drugs and Crime , 2010).

– In 2011, 4.5 million Americans over the age of 12 were current nonmedical users of painkillers and an additional 620,000 were past year users of heroin (Substance Abuse and Mental Health Services Administration, 2012).

– 1.8 million persons suffered from a pain reliever abuse or dependence in 2011 (Substance Abuse and Mental Health Services Administration, 2012).

– Opioid pain relievers accounted for 14,800 drug overdose deaths in 2008 (Centers for Disease Control and Prevention, 2011).

– The societal costs of opioid abuse, dependence and misuse including health care consumption, lost productivity and criminal justice costs and were estimated at $55.7 billion (Birnbaum, 2011).

Read the entire study on the internet.




Read Straight Talk About Addiction
By Terence T. Gorski

The GORSKI-CENAPS Model: A Comprehensive Overview

December 31, 2013

Recovery and Relapse Prevention
A Comprehensive Overview of a

Research-Based System that Works

By Terence T. Gorski
The CENAPS® Corporation

This is the resource for people using the GORSKI-CENAPS MODEL who are looking for a comprehensive overview and complete references upon which the model was based. Be pass it on to people who have any questions about the basis of this model.

Web site or E-mail:
Terry Gorski’s Blog:; email: 

© 2007 Terence T. Gorski
ISBN: 978-0-8309-
Printed in the United States of America

This booklet describes The GORSKI- CENAPS Model of Recovery & Relapse Prevention and the research upon which it was based.  An initial paper: titled The CENAPS Model Relapse Prevention Therapy (RPT) A Description Of Counseling Approaches was developed for The National Institute On Drug Abuse (NIDA) Study To Identify And Describe Drug Abuse Counseling Approaches.  Terence T. Gorski, President of the CENAPS® Corporation, developed this paper.  The original paper was submitted to Kathleen M. Carroll, Ph.D., Assistant Professor of Psychiatry, Director of Psychotherapy Research, Division of Substance Abuse, Department of Psychiatry School of Medicine. In 1993 Terence T. Gorski copyrighted this original paper before it was submitted to NIDA.  Full permission was granted by the copyright holder for NIDA to reproduce and distribute that paper.

The original paper was also submitted to Diane Clark of the Infinity Conference Group Incorporated, 11781 Lee Jackson Highway, Suite 185, Fairfax, VA 22033, on April 30, 1993 as part of a NIDA study in best practices current in the NIDA Archive. The Gorski-CENAPS Model is also the basis for TAP 19: Relapse Prevention With Chemically Dependent Offenders. The first comprehensive overview of the Gorski-CENAPS Model was published in The Journal of Psychoactive Drugs In 1990.

Table of Contents

Part 1: Overview of the GORSKI-CENAPS® Model … 3

General Description (Revised December 31, 2013) … 3
Research Basis…. 3
Theoretical Models. … 4
Target Population … 9
Adaptation To Special Populations … 9
Levels of Clinical Application. … 10
Counselor Characteristics. …  12
Compatibility With Other Models and Standards … 14
Approaches Most Similar … 15
Compatibility With Standards. …  17
Setting of Treatment. … 17
Duration of Treatment … 18

Part 2: An Overview of the GORSKI-CENAPS® Model … 20

The Conceptual Models of the GORSKI-CENAPS® System … 20

Biopsychosocial Model of Addiction (Revised December 31, 2012) … 20

Developmental Model of Recovery: … . 21
Relapse Prevention Model … 22

Cognitive, Affective, Behavioral, Social (CABS) Therapy … 23
Treatment Planning Components. … 23
Helping Characteristics: … 25
Interviewing Skills. … 26
Treatment Delivery Systems. … 27
Strategies For Dealing With Common Clinical Problems. … 32

The GORSKI-CENAPS® Corporation … 35

References On The GORSKI-CENAPS® Model … 36

Bibliography On The Recovery Process … 40

Part 1: Overview of the GORSKI-CENAPS® Model

General Description (Revised December 31, 2013)

The GORSKI-CENAPS® Model of Recovery and Relapse Prevention is a comprehensive system for diagnosing and treating substance use disorders, and coexisting mental disorders, personality disorders and situational life problems.  The Model is based upon a biopsychosocial model of addiction, a developmental model of recovery, and a relapse prevention model.  The model integrates addiction-specific treatment methods with state-of-the-art cognitive, affective, behavioral, and social therapies.

Research Basis

The GORSKI-CENAPS® Model is a research-based system. It complies with all of the evidence-based practices of Relapse Prevention Therapy (RPT) developed by the National Registry of Evidence-based Program and Practices.

The Gorski-CENAPS Model is evolutionary because it includes the strengths of a wide variety of clinical models while transcending their limitations. The GORSKI-CENAPS® Model is dynamic because it is designed to grow by integrating new research findings while adapting to current fiscal constraints.  The model is designed to be used in cross-disciplinary environments staffed by multidisciplinary treatment providers. The model uses plain, no-nonsense language whenever possible and it seeks to avoid professional jargon. As a result it can be easily adapted to the personal clinical style of therapists and program managers while meeting the individualized recovery needs of clients. Today there are many thousands of professionals who have been trained in the GORSKI-CENAPS® Model over the past forty years.

The research basis that supports the model comes from a variety of different sources.

1.  Clinical Modeling:  The original version of the GORSKI-CENAPS model was developed based upon direct observations of the phenomena of addiction, recovery, and relapse.  Direct clinical experiences with addicted patients at three different centers provided observation of the symptomatology of addiction at various stages of severity, the recovery process over periods of up to two years of outpatient treatment, and the relapse process.  These observations were carefully documented and synthesized into a descriptive model.

2.  Literature Reviews:  Ongoing literature reviews were conducted starting in 2013 and new research advances were carefully integrated into various components of the model.

3.  Single Case Research Studies: Over one thousand Relapse Prevention case studies, which demonstrate that over 80% of the cases managed to stop an ongoing series of progressive relapse episodes were conducted in accordance with the National Relapse Prevention Certification School.

4.  Outcome Studies:  Several outcomes studies were conducted by treatment programs using the GORSKI-CENAPS Model and compared to the outcomes of other programs.  These studies consistently showed that overall abstinence of between 60% and 80% were achieved after one year and that relapse-prone clients were able to achieve outcomes as a result of relapse prevention programs that were equal to clients completing treatment for the first time.

5.  Controlled Studies: A NIDA study by Miller[1], on Gorski’s 37 Relapse Warning Signs was conducted and showed that these warning signs were highly predictive of relapse.

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) difficulty 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.

This early research was based on the analysis of 49 supportive scientific studies (NIAAA 1996) [9]

The Developmental Model of Recovery (DMR)

The Developmental Model of Recovery (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[10], as a training manual in 1985[11], and by Hazelden in 1989[12].

The Developmental Model of Recovery used in the GORSKI-CENAPS® Model is consistent with the Stages of Change Model developed by Prochaska and Diclemente[13] and the Developmental Model of Recovery developed by Stephanie Brown[14].

6.         The Relapse Prevention Model

The Relapse Prevention Model is consistent with the original cognitive model of relapse prevention (Marlatt & Gordon 1988[15]), state-of-the-art relapse prevention methods described in the Comprehensive Textbook of Substance Abuse (Daley & Marlatt 1997 [16]) Relapse Prevention has been demonstrated to be effective by a number of research studies.  A meta-analysis (Bowers et al 1999) was performed to evaluate the overall effectiveness of Relapse Prevention and the extent to which certain variables may relate to treatment outcome. Twenty-six published and unpublished studies with 70 hypothesis tests representing a sample of 9,504 participants were included in the analysis. Results indicated that Relapse Prevention was generally effective, especially for clients with alcohol and drug problems. (Irvin et al 1999) [17]

Target Population

The patients who do well with the GORSKI-CENAPS® Model are the same types of patients who do well with other cognitive-behavioral addiction treatment approaches.  The model also does extremely well with clients who have been previously treated with other addiction treatment models and have relapsed.  The general characteristics of patients who do well are those who:

1.  Have average or above average conceptual skills

2.  Have 6th grade or above reading and writing skills.

3.  Are currently abstinent from alcohol and other drugs and free of the symptoms of acute alcohol and drug withdrawal.

4.  Do not have severe learning disabilities, cognitive impairments, or other active psychiatric symptoms that interfere with the ability to participate in a structured cognitive-behavioral therapy program.

Patients who do not do well with the GORSKI-CENAPS® Model are those with severely impaired conceptual abilities, significant literacy problems, serious organic impairments that interfere with the ability to learn and process information, learning disabilities, or other mental disorders that interfere with their ability to respond to cognitive behavioral therapy interventions.

Adaptation To Special Populations

The GORSKI-CENAPS® Model has been adapted to meet the needs of a variety of patient populations including

1.  Patients addicted to a variety of mind-altering substances including alcohol, sedatives, sleeping pills, stimulants (such as cocaine, methamphetamine, and amphetamine), narcotics (such as heroine Demerol, and codeine), psychedelic drugs (such as LSD), and club drugs.

2.  Adults

3.  Adolescents

4.  Families

5.   Addicted patients with pain disorders

6.   Relapse-prone African Americans

7.   Relapse-prone Native Americans

8.   Addicted patients with coexisting eating disorders

9.   Revolving door, indigent detox patients

10. Physically and sexually abused men and women

11.  Addicted offenders in the criminal justice system both behind bars and under community supervision

12.  Addicted patients with a wide variety of coexisting Axis I Psychiatric Disorders (after debilitating initial symptoms have been stabilized with medication)

13.  Addicted patients with a wide variety of coexisting Axis II Personality Disorders

Levels of Clinical Application

The GORSKI-CENAPS® Model is designed to be used on one of two levels:

1.  Level 1:  The Counseling Level:  Patients need to learn new ways of thinking and acting that will allow them to manage high-risk situations and other problems that occur in their lives without using alcohol or drugs.  The primary focus is to teach the client how to do something different when they encounter these situations.  Patients are taught to identify and more effectively manage the thoughts and feelings that get in the way of learning new and more effective ways of dealing with problem situations.

2.   Level 2:  The Psychotherapy Level:  These situations are created by repetitive self-defeating behaviors that are motivated by core personality and lifestyle problems.  These basic mistaken beliefs about self, others, and the world motivate clients to become involved in and mismanage high-risk situations in spite of their conscious intent not to.

  • Core personality problems are self-defeating habits of thinking, feeling, acting, and relating to others.
  • Core lifestyle problems are the habitual ways of living and the agreements and relationships that we establish with other people at work, in the community, with friends, family, and lovers.  These core lifestyle problems are a social structure that both supports and justifies the personality problems.

There are two different types of treatment designed to address these two different levels of client problems.

1.  Counseling:  Counseling is the process of teaching clients how to identify and manage high-risk situations and to identify and change the patterns of thinking, feeling, and acting that prevent them from effectively managing the situation.  This is called Relapse Prevention Counseling.

2.  Psychotherapy:  Psychotherapy is the process of teaching clients how to identify and manage the core personality and lifestyle problems that cause them to keep putting themselves in high risk situations.  It then teaches them how to identify and change the core belief systems and unconscious life rules that create and maintain their personality and lifestyle.  This is called Relapse Prevention Therapy.

The GORSKI-CENAPS® Model has components that can address both levels of problems, but it is recommended that clinicians working at the psychotherapy level have a background in both addiction counseling and advanced clinical training in psychotherapy.

The following general decision rules are applied for determining when to work at the counseling or psychotherapy level.

1.  Clients must be able to stay abstinent from alcohol and drugs before they can successfully work on psychotherapy issues.

2.  Clients should be able to identify and manage high-risk situations at a counseling level without using alcohol or drugs before moving into Psychotherapy.

3.  Focusing treatment upon core personality and lifestyle issues can defocus clients from identifying and managing high-risk situations that can cause alcohol and drug use.  As a result, a premature focus upon psychotherapy can increase the risk of relapse.

4.  Working on the psychotherapy issues can also increase pain and stress.  This makes it even more difficult for the client to manage the high-risk situation.

5.  Every high-risk situation is like the tip of an iceberg.  It sits on top of a cluster of underlying personality and lifestyle problems.  These underlying problems are often surfaced when the client starts learning how to identify and manage the high-risk situation.

6.  It is often difficult to keep the client focused upon learning how to manage the high-risk situation when these deeper issues get activated.  The client wants to focus upon the deeper issue because it is easier to look at psychotherapy issues than to focus upon learning basic abstinence skills.  Since these issues are real and cause the client pain and discomfort, the counselor often feels obligated to work on these issues

7.  It is inappropriate to ignore core personality and lifestyle issues or communicate to the client that these issues are not important.  The client will have to resolve these issues if they are to learn how to maintain long-term abstinence.  The issue is, there are other immediate situations that represent an immediate risk to abstinence.  These issues must be dealt with first.  Later we will review a technique called Bookmarking that will allow us to honor core personality and lifestyle issues as they come while keeping the primary focus upon identifying and managing the high-risk situations that can cause alcohol and drug use.

Counselor Characteristics

Educational Requirements:  Professionals with a variety of degree credentials, ranging from non-degreed Certified Addiction Counselors to Doctoral Level Clinical Psychologists, have been trained and successfully practice the GORSKI-CENAPS® Model of Relapse Prevention Therapy.  The more training in chemical dependency treatment and cognitive behavioral therapy, the more effective the clinician is in utilizing the GORSKI-CENAPS® Model.

As a general rule Certified Addiction Counselors, without Baccalaureate level degrees, utilize the model at the counseling level under the supervision of a Certified Addiction Counselor with a Masters or Doctoral Degree.  The advanced psychotherapy approaches are often restricted to Certified Addiction Counselors with a Master’s Degree or equivalent experience.

Training, Credentials, And Experience:  Many counselors and therapists are able to use GORSKI-CENAPS® Model techniques effectively after reading published literature on the model.  Many programs for example, have installed relapse prevention programs based upon the book Staying Sober: A Guide for Relapse Prevention, the Staying Sober Workbook, and the Staying Sober Recovery Education Modules.  Newer publications have updated and expanded the GORSKI-CENAPS® Model into a wider range of application.  The Denial Management Counseling (DMC) Workbook and the Denial Management Counseling (DMC) Professional Guide have focused the model on the needs of clients with strong denial and treatment resistance.  The Relapse Prevention Counseling (RPC) Workbook has expanded the model into specific applications of managing high-risk situations.  The Relapse Prevention Therapy (RPT) Workbook focuses upon the identification and management of core personality and lifestyle problems that lead to relapse later in recovery after initial stabilization has been achieved.  The Addiction-Free Pain Management Workbook and it’s related Addiction-Free Pain Management Professional Guide apply the model to special needs of recovering people with chronic pain disorders and people who have become addicted to prescription pain medication.  These and other materials clearly outline the basic theories and clinical procedures and provide patient materials for implementation.  Clinical skills training programs and an optional competency certification procedure are available for most components.

Counselor Recovery Status:  Whether a counselor is in recovery from addiction or not is irrelevant to the delivery of the GORSKI-CENAPS® Model of Relapse Prevention Therapy.  It is important that the therapist believe in abstinence-based treatment, avoid the use of harsh psychonoxious confrontation, have good communication skills, have well developed helping characteristics, and be able to role model a functional and sober life style.  The capacity for empathy with the relapse-prone patient is essential.

Ideal Personal Characteristics of the Counselor:  Ideally, therapists using the GORSKI-CENAPS® Model would be recovering chemically dependent people who recovered using GORSKI-CENAPS® therapy methods, who currently have over five years of uninterrupted sobriety, and who have earned a masters degree or above with advanced training in cognitive, affective, and behavioral therapy techniques.

Therapist Behaviors:  The GORSKI-CENAPS® Model trains therapists to enter into a collaborative relationship with their patients and use supportive and directive approaches which avoid harsh confrontation.  Therapists need to have the ability to clearly set and firmly enforce limits while avoiding the extremes.  One extreme to be avoided is becoming overly controlling and punitive.  The other extreme to be avoided is to become overly compliant with the clients demands and using enabling behaviors.  A foundation of good basic counseling and therapy skills are required.

The Role of the Counselor/Therapist:  The counselor or therapist plays the role of educator, collaborator, and therapist.  The counselor has a prescribed series of recovery and relapse prevention exercises that guide a patient through the context of group and individual therapy sessions and structured psycho-education programs.  The goal is to explain each procedure or exercise, assign appropriate homework preparation, and process the results of the exercise in group and individual therapy.  The goal is to help patients recognize and manage relapse warning signs by facilitating insight, catharsis, and behavior change.

The Role of the Patient/Client:  The patient is expected to play an active role in the relapse prevention therapy process.  The patient is given a series of assignments and is expected to actively process those assignments in group and individual therapy sessions.  Many of the assignments involve peer support and sharing of information and experiences.

Typical Sessions:  The GORSKI-CENAPS® Model uses structured problem-solving group therapy, individual therapy, and psycho-educational session formats.  Patients are asked to make a commitment to a structured recovery program including self-help groups and holistic health programs including proper diet, exercise, and social and spiritual activities.

Topics or Themes:  Therapy is primarily directed toward the identification and management of relapse warning signs.  This model consists of structured exercises, which have been developed, with over 20 years of clinical experience.  These are presented in detail in the Staying Sober Workbook, The Relapse Prevention Workbooks

Manualized Treatment (Patient Workbooks): The most effective treatment programs utilize a manualized clinical system that includes reading assignments, journal assignments and self-assessment questionnaires, and preparation assignments for group and individual therapy sessions. Effective manualized treatment needs to match the content of treatment manuals and the modalities in which the content is processed with the problems of the client.

The primary focus of all sessions is to guide the patient in the completion of structured exercises contained in a patient workbook.  Workbooks are available for Denial Management, 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 custom designing treatment manuals (i.e. client workbooks) that address specific recurrent issues within treatment programs.

All applications of the GORSKI-CENAPS® Model rely on the use of core clinical skills 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:  The ability to identify self-talk, feelings and emotions, and urges to act.

2.   Social Awareness Skills:  The ability to observe and accurately assess the behavior of others.

3.   Cognitive Skills:  The ability to identify and challenge addictive and irrational forms of thinking.

4.   Affective Skills:  The ability to recognize feelings and emotions, accurately describing them in words, and communicating them to others when appropriate.

5.   Behavioral Skills:  The two core behavioral skills are 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:  A relationship building model based upon levels of relationship is used to guide clients in slowly rebuilding their social network.  The core social skills involved in the social rebuilding process are: 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:  The ability to identify and develop a personalized list of the unique personal problems that lead the person back to alcohol and drug use (called relapse warning signs) and problem or warning sign management strategies which consist of concrete situational and behavioral coping strategies for managing the warning signs without returning to chemical use.

8.  Recovery Program Development:  Patients are taught how to develop a structured recovery program, which provides a regular daily structure for maintaining a healthy and sober life style.  Breaks in the recovery program are viewed as critical relapse warning signs and immediate intervention is initiated when they become apparent.

Amount of Structure:  The program is highly structured and compliance with the basic therapeutic structures is strongly emphasized as a prerequisite for involvement.

Compatibility With Other Models and Standards

The GORSKI-CENAPS® Model of Treatment for Substance Use Disorders and related personality, mental, and lifestyle problems has been under development since the early 1970’s.[18].  It integrates the fundamental principles of Alcoholics Anonymous (AA) with the most recent advances in biological, cognitive, affective, behavioral, and social therapies to meet the needs of relapse-prone patients.

The GORSKI-CENAPS® Model can be described as the third wave of chemical dependency treatment.  The first wave was the introduction of the Twelve Steps of Alcoholics Anonymous.  The second wave was the integration of AA with professional treatment into a model known as the Minnesota Model.

The GORSKI-CENAPS® Model is the third wave in chemical dependency treatment because it integrates knowledge of chemical dependency into a biopsychosocial model that is compatible with Twelve-Step Principles and biological, cognitive, affective, behavioral, and social therapy principles to produce a model for assessment and treatment planning for use during all stages of the recovery process.

The GORSKI-CENAPS® Model is a comprehensive system for diagnosing and treating substance use disorders and related mental disorders, personality disorders, and lifestyle problems.  The model has been used successfully since the early 1970’s in addiction, mental health, and behavioral health treatment programs.

The GORSKI-CENAPS® Model has been successfully adapted for use in all levels of care, with a wide variety of clients including: women, adolescents, gays, lesbians, African Americans, Native Americans, Hispanic Americans, clients with chronic pain, and clients with other coexisting disorders being treated in community mental health centers.

The GORSKI-CENAPS® Model has been translated into a number of languages including Spanish, Polish, Danish, Swedish, Hungarian, Japanese, Korean, Bangla, Russian, Arabic, and Slovenian.

The GORSKI-CENAPS® Model has been used effectively under a wide variety of health care financing plans including: private insurance, federal funding, state funding, managed care plans, health maintenance organizations, and self-pay private practices.

The reason the GORSKI-CENAPS® Model has survived and thrived under such a variety of financing schemes is because it is based upon rock-solid clinical principles that are flexible enough to adapt to changing conditions in the health care field.

Approaches Most Similar

The GORSKI-CENAPS® Model of Relapse Prevention Therapy is an applied and expanded cognitive-behavioral therapy program that incorporates biological and social treatment.  Its cognitive components are similar to Albert Ellis’s Rational Emotive Therapy (RET) and Aaron Beck’s Cognitive Therapy Model.  Its affective components are similar to Affective and Experiential Therapies, and its social interventions are built upon family systems therapy and the public health model. The primary difference between the GORSKI-CENAPS® Model and the other forms of therapy is that the GORSKI-CENAPS® Model applies cognitive-behavioral therapy principles directly to the problem of treating substance use disorders and teaching chemically dependent patients and their families how to maintain abstinence from alcohol and drugs.

The GORSKI-CENAPS® Model of Relapse Prevention Therapy heavily emphasizes affective therapy principles by focusing upon the identification, appropriate labeling, and communication and resolution of feelings and emotions.  The GORSKI-CENAPS® Model integrates a cognitive and affective therapy model for understanding emotions by teaching patients that emotions are generated by irrational thinking (cognitive theory) and are traumatically stored or repressed (affective theory).  Emotional integration work involves both cognitive labeling and expression of feelings, and imagery-oriented therapies designed to surface repressed memories.  The model relies heavily upon guided imagery, spontaneous imagery, sentence completion, and sentence repetition work designed to create corrective emotional experiences.

This model is similar to and has been heavily influenced by the Cognitive-Behavioral Relapse Prevention Model developed by Marlatt and Gordon[19] [20].  The major difference is that The GORSKI-CENAPS® Model integrates abstinence-based treatment and has greater compatibility with Twelve Step Programs than the Marlatt and Gordon Model.

The GORSKI-CENAPS® Model integrates well with a variety of cognitive, affective, behavioral, and social therapies.  Its primary strength is that this model allows clinicians from varying clinical backgrounds to apply their skills directly to relapse prevention.  As a result, it is ideal for use by a multi-disciplinary treatment team.

Approaches Most Different:  The GORSKI-CENAPS® Model of Relapse Prevention Therapy is most dissimilar to the following types of therapy:  (1) those that view chemical dependency as a symptom of an underlying mental or psychological problem; (2) controlled drinking or self-control training that promotes controlled or responsible use for chemically dependent patients who have exhibited physical and psychological dependence upon alcohol and other drugs; (3) non-directive or client-centered approaches; (4) any form of therapy that isolates or exclusively focuses upon any single domain of physical, psychological, or social functioning to the exclusion of the other domains of functioning.

The GORSKI-CENAPS® Model is very different from rigid cognitive therapy models which believe the challenging of irrational thoughts will bring automatic emotional integration, or rigid affective therapy models which believe that emotional catharsis will automatically cause spontaneous cognitive and behavioral changes.

Compatibility with Other Treatments:  The GORSKI-CENAPS® Model is compatible with a variety of other treatments including Twelve Step Programs, family therapy, and a variety of cognitive, affective, and behavioral therapy models.

The GORSKI-CENAPS® Model also works well with court drug-diversion programs and employee assistance programs.

A special Occupation Relapse Prevention Protocol has been developed for use in conjunction with EAP program referrals which focuses upon the identification of on-the-job relapse warning signs and teaches EAP counselors and supervisors how to intervene upon those warning signs as part of the supervision and corrective discipline process.

A special protocol for working with chemically dependent criminal offenders has also been developed which integrates the treatment of criminal thinking and antisocial personality disorders with chemical dependency recovery and relapse prevention methods.

Specialty application of the GORSKI-CENAPS® Model of Relapse Prevention Therapy has also been developed for patients with Post Traumatic Stress Disorder (PTSD) resulting from childhood physical and sexual abuse[21].

Since the protocol identifies and develops management strategies for a variety of problems that cause relapse, coexisting mental disorders and lifestyle problems are often identified and treated in conjunction with relapse prevention therapy.

A special protocol for family therapy was developed to facilitate family involvement in warning sign identification and management.  Johnson-style family intervention methods were adapted for use in a family-oriented Early Relapse Intervention Plan.

Compatibility With Standards

The GORSKI-CENAPS® Model is fully compatible with: DSM IV, ASAM Patient Placement Criteria, the standards of the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the standards of CARF, and the Core Counselor Competencies as published by the Center for Substance Abuse Treatment (CSAT), The International Certification and Reciprocity Consortium (IC&RC), and the National Association of Alcohol and Drug Abuse Counselors (NAADAC).

Setting of Treatment

The GORSKI-CENAPS Model is designed for implementation across all levels of care.  Since it is based upon a developmental model of recovery that recognizes the possibility of regression, decomposition and relapse at any stage of the recovery process, the ability to step up or step down the level of care based upon clients current level of stability is built into the system.

Typically patients are detoxified in a variable length of stay in inpatient or residential programs or highly structured outpatient detoxification programs.  During detoxification, the patient is stabilized, assessed, and motivated to continue with the GORSKI-CENAPS® Model of Relapse Prevention Therapy in a primary outpatient program.  Severely impaired patients are motivated for transfer to a residential rehabilitation program, therapeutic community program, or halfway house program dependent upon their needs.

Patients who have completed detoxification and are less severely impaired and patients who have successfully completed residential treatment, halfway house, and therapeutic communities are transferred into a primary outpatient program consisting of a minimum of twelve group sessions, ten individual therapy sessions, and six psycho-educational sessions administered over a period of six weeks.  Patients with literacy problems, cognitive impairments, or mental and personality disorders usually require longer lengths of stay to complete the therapeutic objectives.

Upon completion of the primary outpatient program, the patient is transferred into an ongoing group and individual therapy program (four group sessions and two individual sessions per month) to implement the warning sign identification and management procedures and update the relapse prevention plan based upon experiences in recovery.

Brief readmission (three to ten days) for residential stabilization may be required should patients return to chemical use, develop severe warning signs that render them out of control, and at high risk of returning to chemical use.

The model is well adapted for use in the criminal justice system with chemically dependent criminal offenders who have antisocial personality disorders.  In the criminal justice system, the GORSKI-CENAPS® Model of Relapse Prevention Therapy is most effective when integrated with the cognitive-behavioral method for identifying and managing criminal thinking.  In such programs, the model needs to be initiated in residential treatment during the last twelve weeks of incarceration, needs to be continued in a halfway setting for a period of three to six months, and must be continued in a primary outpatient program for a minimal period of two years.

Duration of Treatment

The GORSKI-CENAPS® Model of Relapse Prevention Therapy can be administered in a variety of settings over a variable number of sessions.

Residential Rehabilitation Model:  The GORSKI-CENAPS® Model was originally utilized in 28-day residential programs and was administered over a course of twenty 90-minute group therapy sessions, twelve individual therapy sessions, and twenty 90-minute psycho-educational sessions.  The protocol was supplemented by involvement in self-help groups.  Patients were then transferred into a 90-day outpatient program consisting of twelve 90-minute group therapy sessions (once per week) and six 60-minute individual therapy sessions (twice per month).  This was supplemented by attendance at 24 Twelve Step Meetings and 6 Relapse Prevention Support Groups.

Intensive Outpatient Program:  The GORSKI-CENAPS® Model of Relapse Prevention Therapy was later utilized in an intensive outpatient program consisting of 10 individual therapy sessions, 12 group therapy sessions, 6 psycho-educational groups, and attendance at 6 Twelve Step Meetings and 6 Relapse Prevention Support Groups.  Patients are then transferred into a 90-day warning sign identification management group consisting of 12 group therapy sessions and 6 individual therapy session and continued involvement in Twelve Step Meetings and Relapse Prevention Support Groups.

Psycho-educational Programs:  The GORSKI-CENAPS® Model has been delivered as a psycho-educational program consisting of between 8 and 24 education sessions ranging from 1.5 to 3.0 hours per session.  Motivated patients with adequate reading and writing skills have been able to benefit from involvement in these programs.  These psycho-educational programs are usually integrated with the residential or primary outpatient programs.

Part 2: An Overview of the GORSKI-CENAPS® Model

The Conceptual Models of the GORSKI-CENAPS® System

The GORSKI-CENAPS® System is built around three primary conceptual models: a Biopsychosocial Model, a Developmental Model of Recovery, and a Relapse Prevention Model. Since the original publication the biopsychosocial model of addiction has come to dominate the behavioral health field.

Biopsychosocial Model of Addiction (Revised December 31, 2012)

The GORSKI-CENAPS Model of Relapse Prevention Therapy is a clinical system that integrates the disease model of chemical dependency and abstinence-based counseling methods with recent advances in cognitive, affective, behavioral, and social therapies.  The method is designed to be delivered across levels of care with a primary focus upon outpatient delivery systems.

The ASAM Definition of Addiction is based largely on the biopsychosocial model of addiction.

Addiction As A Primary Disorder:  The GORSKI-CENAPS® Model is based upon a biopsychosocial model which states that chemical dependency is a primary disease or disorder resulting in abuse of, addiction to, and dependence upon mind-altering chemicals.  Long-term use of mood-altering chemicals causes brain dysfunction that disorganizes personality and causes social and occupational problems.

Brain Dysfunction:  Brain dysfunction occurs during periods of intoxication, short-term withdrawal, and long-term withdrawal.  Patients with a genetic history of addiction appear to be more susceptible to this brain dysfunction.  As the addiction progresses, the symptoms of this brain dysfunction cause difficulty in thinking clearly, managing feelings and emotions, remembering things, sleeping restfully, recognizing and managing stress, and psychomotor coordination.  The symptoms are most severe during the first 6 – 18 months of sobriety, but there is a life-long tendency of these symptoms to return during times of physical or psychosocial stress.

Personality Disorganization:  Personality disorganization occurs because the brain dysfunction interferes with normal thinking, feeling, and acting.  Some of the personality disorganization is temporary and will spontaneously subside with abstinence as the brain recovers from the dysfunction.  Other personality traits will become deeply habituated during the addiction and will require treatment in order to subside.

Social Dysfunction:  Social dysfunction, including family, work, legal, and financial problems, emerges as a consequence of brain dysfunction and resultant personality disorganization.

Goal of Treatment:  The GORSKI-CENAPS® Model is based upon the belief that total abstinence plus personality and lifestyle change is essential for full recovery.  People raised in dysfunctional families often develop self-defeating personality styles (which AA calls character defects) that interfere with their ability to recover.  Addiction is a chronic disease that has a tendency toward relapse.  Relapse is the process of becoming dysfunctional in recovery that ends in physical or emotional collapse, suicide, or self- medication with alcohol or drugs.  The GORSKI-CENAPS® Model incorporates the role of brain dysfunction, personality disorganization, social dysfunction, and family of origin problems to the problems of recovery and relapse.

Addiction and Personality:  Addiction can be influenced, not caused, by self-defeating personality traits that result from being raised in a dysfunctional family.  Personality is the habitual way of thinking, feeling, acting, and relating to others that develops in children and is unconsciously perpetuated in adult living.  Personality develops as a result of an interaction between genetically inherited traits and family environment.

Being raised in a dysfunctional family can result in self-defeating personality traits or disorders.  These traits and disorders do not cause the addiction to occur.  They can cause a more rapid progression of the addiction, make it difficult to recognize and seek treatment during the early stages of the addiction, or make it difficult to benefit from treatment.  Self-defeating personality traits and disorders also increase the risk of relapse.  As a result, family-of-origin problems need to be appropriately addressed in treatment.

Drug-based and Abstinence-based Symptoms:  The disease is a double-edged sword with two cutting edges—drug-based symptoms which manifest themselves during active episodes of chemical use and sobriety-based symptoms which emerge during periods of abstinence.  The abstinence-based symptoms create a tendency toward relapse that is part of the disease itself.

The Relapse Syndrome:  The relapse syndrome is an integral part of the addictive disease process.  Relapse is the process of becoming dysfunctional in sobriety due to sobriety-based symptoms that lead to either renewed alcohol or drug use, physical or emotional collapse, or suicide.  The relapse process is marked by predictable and identifiable warning signs that begin long before alcohol and drug use or collapse occurs.  Relapse Prevention Therapy teaches patients to recognize and manage these warning signs and to interrupt the relapse progression early and return to positive progress in recovery.

Biopsychosocial Model of Treatment:  The GORSKI-CENAPS® Biopsychosocial Model is a tightly integrated and complete system for biopsychosocial assessment and treatment.  This biopsychosocial perspective makes the GORSKI-CENAPS® Model an excellent tool for integrating the efforts multidisciplinary treatment teams.  The GORSKI-CENAPS® Model integrates: Biological Interventions such as detoxification and medication management; Psychological Interventions based upon cognitive, affective, and behavioral methods; Social and Cultural Interventions such as family therapy, employment counseling, legal counseling and financial counseling. The ASAM Definition of Addiction is based largely on the biopsychosocial model of addiction.

Developmental Model of Recovery

The GORSKI-CENAPS® Developmental Model of Recovery is based upon the belief that addiction and its related mental and personality disorders are chronic lifestyle- related conditions that require a long-term developmental process of recovery.  This model is very similar to the research model of Stephanie Brown and Prochasca.  The CENAPS® developmental recovery process is conceptualized as moving through a series of six stages.

Stage 0—Active Addiction:  During this stage substance abusers are actively using alcohol and other drugs, receiving substantial perceived benefits from their use, experiencing few perceived adverse consequences, and as a result see no reason to seek treatment.

Stage 1: Transition:  During The Transition Stage the primary focus is upon interrupting denial and treatment resistance.

Stage 2: Stabilization:  During The Stabilization Stage the primary focus is upon breaking the addiction cycle, managing withdrawal, stabilizing mental status, and managing situational life crises.

Stage 3:  Early Recovery:  During the Early Recovery Stage the primary focus is upon teaching patients about addiction and its related mental and personality disorders, teaching them about the recovery process, helping them establish a structured recovery program, and teaching basic skills for identifying and changing addictive thoughts, feelings, behaviors to sobriety-centered thoughts, feelings, and behaviors.

Stage 4: Middle Recovery:  During the Middle Recovery Stage the primary focus is upon repairing damage caused by the addiction to significant others in the areas of work, social, intimate, and friendship systems and to develop a balanced and healthy life style.

Stage 5: Late Recovery:  During Late Recovery the focus is upon helping the person make changes in self-defeating personality styles and self-defeating lifestyle structures that interfere with maintaining sobriety and responsibility.  During this stage the person needs to deal with family of origin issues, which impair the quality of recovery and act as long-term relapse triggers.

Stage 6: Maintenance:  During the Maintenance Stage the primary focus is upon the maintenance of sobriety and responsibility while actively participating in the developmental life process so as not to slip back into old addictive patterns.

Relapse Prevention Model

The GORSKI-CENAPS® Relapse Prevention Model is designed to reduce the frequency, duration and severity of relapse episodes by teaching clients to identify and manage high risk situations that cause relapse in early recovery and the core personality and lifestyle problems that contribute to relapse latter in recovery after initial stabilization has been achieved.  There is also a relapse early intervention component designed to stop relapse quickly should it occur and get the person back into a treatment and recovery program.

Relapse Prevention:  Clients are taught to prevent relapse by using three specific methods:  (1) Relapse Prevention Counseling (RPC) which teaches clients to identify and manage the high-risk situations that can activate craving or cause an immediate relapse; (2) Relapse Prevention Therapy (RPT) which teaches clients to identify and manage the core personality and life style problems that cause unnecessary stress, pain, and problems in recovery; and (3) Relapse Early Intervention which teaches clients to stop relapse quickly should it occur by using Relapse Early Intervention Methods

Cognitive, Affective, Behavioral, Social (CABS) Therapy

The GORSKI-CENAPS® Model of Relapse Management is based upon a balanced biopsychosocial model that recognizes three primary psychological domains of functioning and three primary social domains of functioning.

The Primary Psychological Systems:  The primary psychological systems are:

(1)  Consciousness System (regulates self-awareness);

(2)  Cognitive System (regulates thinking),

(3)  Affective system (regulates feeling and emotion)

(4)  Imagery System (regulates imagination or sensory image formation) as it applies to the personal time line (past, present, and future)

(5)  Behavioral System (regulates motivation and action). Imagery is viewed as a primary mediating function between thinking, feeling, and acting.  The GORSKI-CENAPS® Model of Relapse Prevention Therapy makes extensive use of both guided imagery for mental rehearsal and spontaneous imagery for cognitive and emotional integration work.

The Primary Social Systems:  The primary social domains are:

(1) Work

(2) Friendship

(3) Intimate /Family

Preferred Modes of Psychosocial Functioning

People usually have a preference for one psychological and one social domain.  These preferred domains become over-developed while the others remain underdeveloped.  The goal is to reinforce the skills in the overdeveloped domains while focusing the client on building skills in the underdeveloped domains.  The goal is to achieve healthy, balanced functioning.

Each of these domains is considered equally important and the clinical goal is to help patients achieve competent functioning within each of these three domains.

Standard Treatment Modalities

The GORSKI-CENAPS® Model of Relapse Prevention Therapy incorporates the use of standard and structured group and individual therapy sessions and psycho-education programs that focus the patients’ attention primarily upon these five primary goals.  The treatment is holistic in nature and involves the patients in a structured program of recovery activities.  Willingness to comply with the recovery structure and actively participate within the structured sessions is a major factor in accepting patients for treatment with this model.

Agent Of Change:

The primary agent of change is the completion of a structured clinical protocol in a process-oriented interaction between the patient, the primary therapist or counselor, and members of the therapy groups.

Treatment Planning Components

The GORSKI-CENAPS® Model consists of six interrelated Treatment Planning Components.  Each of these treatment planning components addresses a common issue that is frequently the central focus of treatment.  When combined together, these five treatment-planning components provide effective guidelines that address 80% of the treatment issues raised by clients in recovery from non-complicated cases of addiction.  These six treatment planning components are:

Component #1: Assessment and Treatment Planning (ATP):  The primary focus: is recognizing addiction and related personality and mental disorders.  This component presents general guidelines for:  (1) completing a comprehensive assessment for addiction and related personality disorders, mental disorders, and situational life problems and (2) developing a brief strategic treatment plan that appropriately matches clients to one of the following treatment planning components.  The selected treatment planning component is then customized to meet the individualized needs of the client.

The Goals of Assessment and Treatment Planning (ATP) are:

(1) Identify substance use disorders, mental disorders, personality disorders, and situational life problems

(2) Write a prioritized list

(3) Develop a short-term brief strategic treatment plan

(4)  Create a long-term recovery vision

(5) Referral to the next appropriate type of treatment

Component #2:  Denial Management Counseling (DMC):  The primary focus is managing denial and resistance.  This component presents a master treatment plan for interrupting denial, overcoming treatment resistance, and motivating participation in treatment.

The Goals of Denial Management Counseling (DMC) are:

(1) Stop denial and resistance

(2) Referring for Primary Recovery Counseling (PRC)

Component #3:  Primary Recovery Counseling (PRC):  The primary focus is learning basic recovery skills.  This component presents a master treatment plan for developing a structured recovery program and teaching foundational recovery skills needed for breaking the addiction cycle and maintaining abstinence.

The Goals Of Primary Recovery Counseling (PRC)

(1) Teach foundational recovery skills

(2) Refer for Relapse Prevention Therapy (RPT)

Component #4:  Relapse Prevention Counseling (RPC):  The primary focus is managing high-risk situations.  This component presents a master treatment plan for identifying and managing high-risk situations that can cause relapse.

The Goals of Relapse Prevention Counseling (RPC)

(1)       Identify and manage high-risk situations that cause relapse

(2)       Referral to the next appropriate type of treatment

Component #5:  Relapse Prevention Therapy (RPT):  The primary focus is managing core personality and lifestyle problems.  This component presents a master treatment plan for Identifying and changing core personality and lifestyle problems that create stress, pain, and problems that can lead to relapse later in recovery after initial abstinence has been achieved.

The Goals of Relapse Prevention Therapy (RPT)

(1)       Identify and manage core personality and lifestyle issues

(2)       Refer for Ongoing Case Management (OCM):  The Primary Focus of Ongoing Case Management is to provide support, monitoring, and access to early intervention.

Component #6:  Dual Disorders Counseling (DDC):  The primary focus is managing addiction-related mental and personality disorders.  This component presents a set of guidelines for integrating the treatment of addiction and the related mental disorders and personality disorders that often lead to relapse if left untreated.

Helping Characteristics

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 perceives 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:  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.

Interviewing Skills

There are seven core therapeutic communication techniques that are used when implementing all GORSKI-CENAPS® treatment plans.  These are:

1. Focused Questioning:  Focused Questioning is an interviewing skill that involves developing and using a sequence of open-ended questions to guide the patient in a systematic process of self exploration.  In DMC the goal of the focused questioning sequences are to interrupt denial and resistance, recognizing and accepting the reality of the substance use disorder, and motivating the client to voluntarily move on to the next phase of treatment.

2.  Active Listening:  Active Listening is an interviewing skill that involves asking a focused question, listening carefully to the answer, using same- word feedback with an accuracy check, using other word feedback (paraphrasing) with an accuracy check, and moving on to the next question.  If used properly active listening helps clients feel listened to, understood, taken seriously and affirmed

3.  Immediate Relaxation Response Training:  Immediate Relaxation Response Training is an interviewing skill that focuses upon keeping stress levels low while exploring difficult issues.  This involves teaching clients to use a subjective stress thermometer to self-monitor stress levels, contracting for time outs if either the client or the therapist sense stress levels are getting too high, and using brief relaxation techniques to immediate lower the stress to functional levels.

4.  Sentence Completion:  Sentence Completion is an interviewing skill that allows clients to quickly identify and clarify core issues by completing a sentence stem multiple times and then selecting and creating new sentence stems from the hot responses on the first sentence completion list.

5.  Sentence Repetition:  Sentence Repetition is an interviewing skill that allows clients to quickly identify strong feelings, memories, and future fantasies that are related to specific self-talk statements.  This skill involves listening for the automatic self-talk associated with hot responses during an interview, making the core activating statement explicit in a sentence, and asking the client to repeat the sentence while self-monitoring for self-talk, strong feelings, action urges, and emerging denial patterns.

6.  Inner Dialogue:  Inner Dialogue is an interviewing skill that is used to help a client identify and clarify the components of internal dissonance.  Most addicted people have an inner conflict between The AddictiveIrresponsible Self, the part of the person that believes that the use of alcohol, drugs, and irresponsible behaviors is good for them; and The Sober Responsible Self, the part of the person that recognizes the problems with alcohol, drugs and irresponsible behaviors.  The inner dialogue technique asks a person to identify the battle between these two sides of their personality and to learn how to engage in conscious dialogue and train the sober responsible self to win the arguments.

7. Bookmarking:  An interviewing skill that identifies and clarifies secondary problems, writes down the problem issues, and formally defers the problem until later in therapy by showing how trying to deal with the problem now would interfere with accomplishing the primary goal of the current treatment.

Treatment Delivery Systems

The GORSKI-CENAPS® Model can use one of three treatment delivery systems: Pyschoeducation Programs, Problem-Solving Group Therapy, and Individual Therapy.

Delivery System #1:  Pyschoeducation Programs:  Pyschoeducation Programs that teach recovery skills to large groups of clients using an experiential adult learning model.  A standard psycho-education group format is used that is based upon proven adult learning principles.

1. Pretest:  Participants are given a pretest to determine their knowledge level at the beginning of the sessions.

2. Lecture:  A brief lecture is given describing the basic information for the class.

3.  Group Exercise:  A group learning exercise is completed that requires all class members to become actively involved in using the material they heard in the lecture.

4.  Post Test:  Participants are given a post test to see if they changed any of their answers as a result of the sessions.

5.  Discussion:  The instructor facilitates a group discussion and question and answer session as he or she reviews the correct answers to the test.

Delivery System #2:  Problem-Solving Group Therapy:  Problem-Solving Group Therapy allows each client to systematically implement the action steps in their treatment plan in a structured support group setting.

The GORSKI-CENAPS® Model of Relapse Prevention Therapy uses a standard session model of problem-solving group therapy that consists of group rules, group responsibilities, a standard group format, and a standard problem-solving procedure.

Group Rules:  The following rules are used as part of the problem-solving group process.

1. Openness: You can say anything you want, any time you want to say it.  Silence is not a virtue in this group and can be harmful to your recovery.

2. Right of Refusal: You can refuse to answer any question or participate in any activity except the basic group responsibilities.  The group cannot force you to participate, but they do have the right to express how they feel about your silence or your choice not to get involved.

3. Confidentiality:  What happens in the group stays among the members with the exception of the counselors who may consult with other counselors in order to provide more effective treatment.

4.  No violence:  No swearing, putting down, physical violence, or threats of violence.  The threat of violence is as good as the act.

5. No Intimate Relationships: No dating, romantic involvement, or sexual involvement among the members of the group.  Such activities can sabotage one or both person’s treatment.  If such involvement starts to develop, bring it to the attention of the group or your individual counselor at once.

6. Freedom to Leave: Anyone who decides to leave group treatment has a responsibility to inform the group in person prior to termination.

7.  Punctuality: Group sessions are two hours in duration.  Patients should be on time and should plan not to leave the session before it is over.  Smoking, eating, and drinking beverages are not allowed in group.

Group Responsibilities:  Group members agree to fulfill the following basic group responsibilities:

1. Give a reaction at the beginning of each session.

2. Volunteer to work on a personal issue in each group session.

3. Complete all assignments and report to the group what you learned from completing them.

4.  Listen to other group members when they present problems.

5. Ask questions to help clarify the problem or proposed solution.

6. Give feedback about how you see the problem and   how you feel about the group member presenting the problem.

7. Share personal experiences with similar problems when appropriate.

8. Complete the closure exercise by reporting to the group what you learned in the session and what you will do differently as a result of what you learned.

Problem-Solving Group Counseling Format:  The group therapy sessions follow a standard eight-part group therapy protocol.  The first and last steps of the protocol (preparation and debriefing sessions) are attended by the therapy team only.  The other steps in the protocol occur during the group therapy session itself.

1. Preparation Session:  The preparation session begins by reviewing patients’ treatment plans, goals, and current progress in implementing treatment interventions.  Each patient’s progress is reviewed and an attempt is made to predict the assignments and problems that the patient will present.

2. Opening Procedure:  (5 minutes) During the opening procedure, the counselor sets the climate for the group, establishes leadership, and helps patients warm up to the group process.

3. Reactions to Last Session:  (15 minutes) A reaction is a brief description of:  (1) What each group member thought during the last group session, (2) How the group member felt during the last group session, and (3) The identification of the three persons who stood out from the last session and why they were remembered.

4. Report On Assignments:  (10 minutes) Assignments are exercises that patients are working to identify and manage relapse warning signs or deal with other problems related to relapse prevention.  Some of these assignments will be completed in group.  Others will need to be completed between group sessions.

Immediately following reactions, the counselor will ask all group members who have received assignments to briefly answer six questions:  (1) What was the assignment and why was it assigned?  (2) Was the assignment completed and, if not, what happened when you tried to do it?  (3) What was learned from the completion of the assignment?  (4) What feelings and emotions were experienced while completing the assignment?  (5) Did any issues surface that require additional work in group?  (6) Is there anything else that you want to work on in group today?

5. Setting the Agenda:  (3 minutes) When all assignments have been reported on, the group counselor will identify all persons who want to work, and announce who and in what order people will work.  Group members who do not have time to present their work in this group session will be first on the agenda in the following group session.  It is best to plan on having no more than three patients working in any group session.

6. Problem-Solving Group Process:  (70 minutes)   The problem-solving group process is designed to allow patients to present issues to the group, clarify these issues through group questioning, receive feedback from the group, receive feedback from the counselor (if appropriate), and develop assignments for continued progress.

7. Closure Exercise:  (15 minutes)  When there is approximately fifteen minutes left in the group session, the group therapist will ask each member to report what is the most important thing they learned in group and what they are going to do differently as a result of what they learned.

8. Debriefing Session:  The debriefing session is designed to review the patient’s problems and progress, prevent counselor burnout, and improve the group skills of the counselor.  If this can be done with other counselors running similar groups, it is especially helpful.  A brief review of each patient is completed, outstanding group members and events are identified, progress and problems discussed, and the personal feelings and reactions of the counselor are reviewed.

Standard Problem-Solving Process:  Group therapy participants learn a standard Problem-Solving Group Process that guides problem resolution.  The seven-step process is:

1.  Problem Identification:  First, have the members ask questions to identify what is causing difficulty.  What is the problem?

2.  Problem Clarification:  Encourage patients to be specific and complete.  Is this the real problem or is there a more fundamental problem?

3.  Identification of Alternatives:  What are some options for dealing with the problem?  Ask patients to list them on paper so they can readily see them.  Try to have the group come up with a list of at least five possible solutions.  This will give them more of a chance of choosing the best solution and give them some alternatives if their first choice doesn’t work.

4.  Projected Consequences of Each Alternative:  What are the best, worse, and most likely outcomes that could be achieved by using each alternative solution.

5.  Decision:  Have the group ask the person which option offers the best outcome and seems to have the best chance for success?  Ask them to make a decision based on the alternatives they have.

6.  Action:  Once they have decided on a solution to the problem, they need to plan how they will carry it out.  The plan should answer the question, “What are you going to do about it?”  A plan is a road map to achieve a goal.  There are short-range goals and long-range goals.  Long-range goals are achieved along with short-range goals — one step at a time.

7.  Follow-Up:  Ask patients to carry out their plans and report how it is working.

Delivery System #3:  Individual Therapy:  Individual Therapy that allows clients to systematically implement the action steps in their treatment plan in individual sessions.  These individual therapy sessions can be used as an exclusive mode of treatment or used in conjunction with Psycho-education and problem-solving group therapy.

The goal of individual therapy is to assist patients in identifying and clarifying problems and preparing to present them in group. A standard agenda is used:

1.         Reactions to Last Session:  The therapist discusses patients’ reactions to the last individual and group therapy session.

2.         Sobriety Check:  The therapist asks patients if they have been clean and sober, if they have experienced any cravings or urges to use alcohol or drugs, if they have attended all scheduled recovery activities, and how they feel about attending those activities.

3.         Clinical Work:  The issues patients are currently working on are reviewed in depth.  During this part of the session, the therapist will present problem identification and clarification work and motivate patients to present issues in group.  If intense cathartic work is required, this is usually done in individual sessions rather than in group therapy sessions.

4.         Preparation For Group:  Patients rehearse how they will present issues to the group.  The primary goal of individual therapy is to prepare and support patients in efficiently working on issues in group.  Group is viewed as the primary or central treatment modality with individual therapy playing a supportive role.

Delivery System #4:  Family Treatment:  The GORSKI-CENAPS® Model has a family treatment component that involves communication and intervention training around the developing warning signs and relapse early intervention training which allows the patient and family member to have a concrete behavioral response should alcohol and drug use recur.

Family therapy is normally delivered in a “parallel model“.  The patient is involved in individual and group therapy for recovery from chemical dependency, and the family members (especially the spouse or intimate partner) is encouraged to enter individual and group therapy for the treatment of codependency and other personal issues.  Sessions are established to work with specific couples and family communication training and problem solving.  Special emphasis is placed upon developing open communication around recovery goals, relapse warning signs for both chemical dependency and codependency, family warning sign identification and management skills, and family intervention planning should alcohol and drug use or acting out codependent behavior occur.

The goal of family therapy is to remove the chemically dependent partner from the identified patient role and create a family recovery focus in which each family member needs to initiate a personal recovery program for chemical dependency or codependency, and the family needs to establish a family recovery plan for improving the overall functioning of the family system.

Family therapy is viewed as important but adjunctive to relapse prevention therapy.  Many relapse-prone patients do not have a committed family system and many family members refuse to become involved in therapy because of the long history of past failure.  Many relapse-prone patients can and do achieve long-term recovery with The GORSKI-CENAPS® Model of Relapse Prevention Therapy even though the family is not involved in treatment.

Delivery System #5:  Support Groups:  Self-help Groups that are related to providing ongoing support and peer assistance while implementing the action steps in their treatment plan.  The GORSKI-CENAPS® Model is compatible with many support groups including Twelve-Step Programs based upon Alcoholics Anonymous (AA), and MISA (Mentally Ill Substance Abusers) Groups.

Because it is based upon a disease model and abstinence-based treatment, the GORSKI-CENAPS® Model is designed to be compatible with Twelve Step Programs.  A special interpretation of the Twelve Steps was developed to help patients relate twelve step program involvement to relapse prevention principles.

Special self-help support groups, called Relapse Prevention Support Groups were developed to encourage patients to continue in ongoing warning sign identification and management. These Relapse Prevention Support Groups can be set up to allow clients to gain low cost peer support while completing specific types of treatment plans.

Delivery System #6:  Multimodality Programs:  Most treatment programs are multimodality in nature.  They use a variety of related clinical models and delivery systems. The GORSKI-CENAPS® Model has been used successfully in the context of a wide variety of multimodality programs directed at a wide variety of special populations.

Strategies For Dealing With Common Clinical Problems

The GORSKI-CENAPS® Model relies heavily upon structured program procedures.  The process is initiated with patient contracting and a commitment is secured for attendance, punctuality, willingness to comply with patient responsibilities, and actively participate within the session structures.  Patients who refuse to make such a commitment are viewed as poor candidates for the program and are not admitted for therapy.

In spite of this initial participation contract, routine problems do develop in treatment.  All such problems are viewed as relapse warning indicators because they place the patient’s ongoing therapy at risk and, hence, increase the risk of relapse.  The following issues are promptly dealt with as critical issues.

Lateness:  Patients are expected to be on time for sessions.  In group, the standard procedure for dealing with lateness is as follows:   (1) prior to entering group, patients contract to be on time for all sessions; (2) If patients arrive late within the first fifteen minutes of group (prior to the end of reactions), they are allowed to stay for that group session only if they agree to work on the issues that prompted the lateness; (3) If patients are more than fifteen minutes late for the first session or less than fifteen minutes late for the second session, they are not allowed in group. They must have an individual session with their therapist prior to being allowed back in group and produce evidence that they have identified and resolved the issued related to lateness; (4) If patients are late on three or more occasions during any twelve-week period of time, they are discharged from group.

Similar no-nonsense procedures are applied to group therapy and individual therapy.  Only extremely credible excuses are honored for absence or tardiness, and this is only if they have not developed a pattern of absence or tardiness.

Missed Sessions:  Patients are expected to attend all therapy sessions.  The only excuse for absence is documented extreme illness (with a physician’s note) and documented serious life crisis such as death in the family.  All excused absences must be telephoned in and must be approved by the therapist in advance.  Any pattern of three or more absences within any twelve-week period is grounds for dismissal regardless of the reasons.

Chemical Relapse and Intoxicated Patients:  Intoxicated patients are not allowed to remain in group.  If the therapist or group members suspect intoxication, the patient is asked to verify it in group.  If the patient denies intoxication but their behavior gives reasonable cause to believe he or she has been using alcohol or drugs, they are immediately given a breath test for alcohol and a urine drug screen.

Appearing intoxicated for session is viewed as a chemical relapse. The patient is immediately removed from group because he or she will be disruptive and cannot benefit from therapy when under the influence of mood-altering drugs.   An immediate screening appointment is established and the patient is admitted to a stabilization program at the appropriate level of care to deal with withdrawal.

The therapist deals with relapse to alcohol and drug use as a medical issue requiring stabilization and treats the patient professionally.  Anger at the patient is viewed as a maladaptive counter-transference response and the therapist needs to resolve that issue in clinical supervision.

Patient refusal to follow recommendations for stabilization results in termination from treatment.  If patients follow stabilization recommendations, they are evaluated at the end of stabilization and are referred to appropriate ongoing treatment.  This usually involves being returned to the same therapist and outpatient group to process the relapse and use material learned to update and revise relapse prevention strategies.

In short, relapse is viewed as part of the disease and is dealt with non-judgmentally and non-punitively.  The relapse is processed so it can become a learning experience for the patient.

Denial, Resistance, And Poor Motivation:  The GORSKI-CENAPS® Model views resistance on a continuum from simple denial of chemical dependency to delusion states based on cognitive impairments or severe personality pathology.  The underlying cause of the denial is assessed and special treatment interventions are set up to deal with it.

Since patients in severe and rigid denial are inappropriate candidates for relapse prevention therapy, they are referred to transitional counseling programs that are designed to deal with patients with high levels of denial and treatment resistance.  Once patients become treatment ready, they can reapply for admission to the Relapse Prevention Therapy Program.

Crisis During Treatment:  Crisis situations are viewed as critical relapse warning signs. The implementation of the standard treatment plan is discontinued and special crisis management procedures are implemented to stabilize the crisis.  Once the crisis is stabilized, the patient is reassessed, the treatment plan is updated, and the patient returns to working on standard relapse prevention tasks as outlined in the treatment plan.

If possible, the crisis is stabilized in the context of the GORSKI-CENAPS® Model of Relapse Prevention Therapy.  If the crisis is so severe that it interferes with the patient’s ability to be involved, he or she   is transferred to another type or level of care to focus upon the crisis stabilization.

The GORSKI-CENAPS® Corporation

The GORSKI-CENAPS® Corporation is a training, consultation and international networking organization committed to the development and dissemination of a unified model for the treatment of substance use disorders and related personality disorders, mental disorders, and lifestyle problems.

Mission:  To promote access to affordable resources for developing effective recovery and relapse prevention plans

Vision:  Better treatment will be available to more people at a lower cost.  All people, no matter how sick, will have the opportunity to recover.  No person or group of persons will be thrown away in the name of cost containment.  A unified no-nonsense model of treatment that integrates the most advanced biological, cognitive, affective, behavioral, and social therapies will be fully operational.  This model will be the recognized standard in the treatment of substance use disorders, mental disorders, personality disorders, and situational life problems.

References On The GORSKI-CENAPS® Model

The following references, listed in chronological order, chart the development of the GORSKI-CENAPS® Model of Relapse Prevention Therapy.

Annis, H.M. (1990) Effective Treatment for Drug and Alcohol Problems: What Do We Know? Substance Abuse and Corrections, Volume 2, Number 4

Beck, Aaron T., Wright, Fred D., Newman, Cory F. and Liese, Bruce S., Cognitive Therapy of substance Abuse, Guilford Press, New York 1993

Berke J. D. and Hyman S. E., “Addiction, Dopamine, and the Molecular Mechanisms of Memory,” Neuron 25 (2000): 515­532 (

Brown, Stephanie, Treating the Alcoholic: A Development Model of Recovery. New York, John Wiley & Sons, 1985.

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

Ellis, Albert, McInerney, John F., DiGiuseppe, Raymond, and Yeager, Raymond J.,  Rational Emotive Therapy With Alcoholics And substance Abusers, Pergamon Press, 1988

Garavan H., Pankiewicz J., Bloom A.,. Cho J. K, Sperry L., Ross T. J., Salmeron B. J., Risinger R., Kelley D., and Stein E. A., “Cue-Induced Cocaine Craving: Neuroanatomical Specificity for Drug Users and Drug Stimuli,” American Journal of Psychiatry 157 (2000): 1789­1798 (

Gorski, T.  The Dynamics of Relapse in the Alcoholic Patient.  Ingalls Memorial Hospital, Harvey, Illinois, (September, 1976).

Gorski, T.  Dynamics of Relapse.  EAP Digest (November/December 1980): 16-21, 45-49.

Gorski, T., and Miller, M.  Counseling for Relapse Prevention.  Herald House/ Independence Press, Independence, Missouri (1982).

Gorski, T., and Miller, M.  Staying Sober:  A Guide for Relapse Prevention.  Herald House/Independence Press, Independence, Missouri (1986).

Gorski, T.  Relapse Prevention Planning:  A New Recovery Tool.  Alcohol Health and Research World (Fall 1986): 6-11, 63.

Gorski, T.  The Staying Sober Workbook:  A Serious Solution for the Problem of Relapse.  Herald House/Independence Press, Independence, Missouri (1988).

Gorski, T.  How To Start Relapse Prevention Support Groups.  Herald House/Independence Press, Independence, Missouri (1989).

Gorski, T.  The Relapse Recovery Grid.  Hazelden, Center City, Minnesota (1989).

Miller, M., and Gorski, T.  Staying Sober Recovery Education Modules. Herald House/Independence Press, Independence, Missouri (1989).

11.      Gorski, T.  The GORSKI-CENAPS® Model of Relapse Prevention Planning.  Journal of Chemical Dependency Treatment, vol. 2, no. 2 (1989):   153-169.

Gorski, T.  The GORSKI-CENAPS® Model of Relapse Prevention:  Basic Principles and Procedures.  Journal of Psychoactive Drugs  (April-June 1990): 125-1

Gorski, T.  Supervisory Guidelines for Counselors in Relapse.  The Counselor (September/October 1990): 12-15.

Gorski, T., and Bell, T.  Recovery and Relapse – Preventing Relapse in Chemically Dependent Adolescents.   Employee Assistance (March 1992): 29,41-42.

Gorski, T.  Relapse – Not A Reason To Give Up.  Addiction & Recovery (March/April 1992): 13-14.

Gorski, T.  Preventing Relapse.  Addiction Counseling World (March/April 1992): 23.

Gorski, T.  Relapse Therapy – Dual Diagnosis and Relapse.  The Counselor (March/April 1992): 48.

Gorski, T.  Creating A Relapse Prevention Program In Your Treatment Center.  Addiction & Recovery (July/August 1992): 16-17.

Gorski, T.  Relapse Prevention in Managed Care.  Journal of Health Care Benefits (July/August 1992): 50-52.

Gorski, T.  Relapse Therapy – Megatrends and Relapse.  The Counselor (July/August 1992): 44.

21.      Gorski, T.  AIDS And Relapse:  Why Stay Sober If I’m Dying?   Addiction & Recovery (January/February 1993): 41-44.

Gorski, T.  Relapse Early Intervention Training.  The Counselor (January/February 1993): 36.

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

George, William H.,  Marlatt and Gordon’s Relapse Prevention Model:  A Cognitive-Behavioral Approach To Understanding And Preventing Relapse, Journal of Chemical Dependency Treatment, vol. 2, no. 2 (1989): 153-169.

Irvin, J.E., Bowers, C.A., Dunn, M.E., Wang, M.C.  “Efficacy of Relapse Prevention: A Meta-Analytic Review,” Journal of Consulting and Clinical Psychology, Source Id: 67(3):563-570, 1999

Leshner A. I., Addiction Is a Brain Disease, Issues of Science & Technology Online, Spring 2001 (

Leshner A. I., “Science-Based Views of Drug Addiction and Its Treatment,” Journal of the American Medical Association 282 (1999): 1314­1316 (

Marlatt, G. A. and Gordon, J. R., Eds.  (1988)  Relapse Prevention:  MaintenanceStrategies in the Treatment of Addictive Behavior.  New York:  Guilford Press, pp. 351-416.

Miller, M., Gorski, T., and Miller, D.  Learning To Live Again – A Guide for Recovery From Alcoholism.  Herald House/Independence Press, Independence, Missouri (1980).

Miller, W.R.; Harris, R.J. “Simple scale of Gorski’s warning signs for relapse.” Journal of Studies on Alcohol, 61(5):759-765, Sept 2000

McLellan A. T., Lewis D. C., O’Brien C. P., and Kleber H. D., “Drug Dependence, a Chronic Medical Illness,” Journal of the American Medical Association 284 (2000): 1689­1695 (

NIAAA – National Institute on Alcohol Abuse and Alcoholism, Alcoholism Report No. 33: Neuroscience Research and Medications Development, PH 366 July 1996

NIDA – National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A Research-Based Guide (National Institutes of Health, Bethesda, MD, July 2000) (

NIDA – National Institute on Drug Abuse, Preventing Drug Use Among Children and Adolescents: A Research-Based Guide (National Institutes of Health, Bethesda, MD, March 1997) (

Nestler E. J., “Genes and Addiction,” Nature Genetics 26 (2000): 277­281 (

Physician Leadership on National Drug Policy, position paper on drug policy (PLNDP Program Office, Brown University, Center for Alcohol and Addiction Studies, Providence, R.I.: January 2000) (

Prochaska, James O., Norcross, John C., & DiClemente, Carlo C., Changing for Good, Wiliam Morrow and Company Inc., New York, 1994

Tabakoff, Boris and Hoffman, Paula L.  A Neurobiological Theory of Alcoholism, IN:  EDS:  Chaudrin CD and Wilkinson DA, Theories On Alcoholism, Addiction Research Foundation, Toronto, Canada 1988

Tarter, Ralph E., Alterman, Arthur I, and Edwards, Kathleen L., Neurobehavioral Theory of Alcoholism Etiology, IN:  EDS:  Chaudrin CD and Wilkinson DA, Theories O

on Alcoholism, Addiction Research Foundation, Toronto, Canada 1988

Taxman F. S. and Bouffard J. A., “The Importance of Systems in Improving Offender Outcomes: New Frontiers in Treatment Integrity,” Justice Research and Policy 2 (2000): 37­58.

Trotter, Caryl, Double Bind: Recovery and Relapse Prevention for The Chemically Dependent Sexual Abuse Survivor, Herald House/Independence Press, Independence, MO, 1992.

Wilson, G. Terence. Alcohol use and Abuse: Social learning Analysis; IN: IN:  EDS:  Chaudrin CD and Wilkinson DA, Theories on Alcoholism, Addiction Research Foundation, Toronto, Canada 1988

Bibliography On The Recovery Process

Brown, Stephanie, Treating the Alcoholic: A Development Model of Recovery. New York, John Wiley & Sons, 1985.

Forrest, Gary G., Intensive Psychotherapy of Alcoholism. Springfield, Illinois, Charles C. Thomas Publisher, 7-1984.

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

Hazelden Foundation, Inc. The Caring Community Series. Center City, Minnesota, 1975.  No.   1: The New Awareness; No.   2: Identification; No.   3: Implementation; No.   4: The Crisis; No.   5: Emergency Care; No.   6: Dealing with Denial; No.   7: The New Understanding; No.   8: Winning by Losing: The Decision; No.   9: Personal Inventory & Planned Re-Entry; No.   10: Challenges to the New Way of Life.

Joseph, Jay, Breslin, Curtis, and Skinner, Harvey; Critical Perspectives on the Transtheoretical Model and Stages of Change; IN:  EDS. Tucker, Julia A., Donovan, Dennis M., and Marlatt, G. Alan; Changing Addictive Behaviors: Bridging Clinical and Public Health Strategies, Skinner, The Guilford Press, New York &  London 1999.

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.

Mulford, H., “Stages in the Alcoholic Process.” Journal of Studies on Alcohol, 1977, 38(3), 563-583.

Prochaska, James O., Norcross, John C., & DiClemente, Carlo C., Changing for Good, Wiliam Morrow and Company Inc., New York, 1994

Rubinston, E., “The First Year of Abstinence: Notes on an Exploratory Study.” Journal of Studies on Alcohol, 1981, 41(5), 577-582.

Tiebout, Harry M., “Therapeutic Mechanisms of Alcoholics Anonymous,” American Journal of Psychiatry, 1947.

Wiseman, J.P., “Sober Comportment: Patterns and Perspectives of Alcohol Addition.” Journal of Studies on Alcohol, 1981, 42(1), 106-126.

Zimberg, N E., Psychotherapy in the Treatment of Alcoholism. In Encyclopedia Handbook of Alcoholism, E. M. Pattison and E. Kaufman (eds.). New York, Garden Press, 1982, pp. 999-1011.

[1] Miller, W.R.; Harris, R.J. Simple scale of Gorski’s warning signs for relapse. Journal of Studies on Alcohol, 61(5):759-765, Sept 2000.

[2] In the literature this model and its related theories are often called the “neurobehavioral model”.  Since the model involves the neuropsychological responses that predispose people to rapidly develop serious problems related to alcohol and drug use I will use the term “neuropsychological predisposition model” because it is more descriptive and helps to distinguish this model from the other models that were integrated into the biopsychosocial model.

[3] Tarter, Ralph E., Alterman, Arthur I, and Edwards, Kathleen L., Neurobehavioral Theory of Alcoholism Etiology, IN:  EDS:  Chaudrin CD and Wilkinson DA, Theories On Alcoholism, Addiction Research Foundation, Toronto, Canada 1988

[4] In the literature, this model and its related theories are often called the “neurobiological model.”  Since the model involves the direct neuropsychological responses to alcohol and drug use, I will use the term “neuropsychological response model” because it is more descriptive and helps distinguish this model from the other models that were integrated into the biopsychosocial model.

[5] Tabakoff, Boris and Hoffman, Paula L.  A Neurobiological Theory of Alcoholism, IN:  EDS:  Chaudrin CD and Wilkinson DA, Theories On Alcoholism, Addiction Research Foundation, Toronto, Canada 1988

[6] Wilson, G. Terence. Alcohol use and Abuse: Social learning Analysis; IN: IN:  EDS:  Chaudrin CD and Wilkinson DA, Theories On Alcoholism, Addiction Research Foundation, Toronto, Canada 1988

[7] Beck, Aaron T., Wright, Fred D., Newman, Cory F. and Liese, Bruce S., Cognitive Therapy of substance Abuse, Guilford Press, New York 1993

[8] Ellis, Albert, McInerney, John F., DiGiuseppe, Raymond, and Yeager, Raymond J.,  Rational Emotive Therapy With Alcoholics And substance Abusers, Pergamon Press, 1988

[9] NIAAA – National Institute on Alcohol Abuse and Alcoholism, Alcoholism Report No. 33: Neuroscience Research and Medications Development, PH 366 July 1996

[10] 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

[11] Gorski, Terence T., The Developmental Model of Recovery: A Workshop Manual. The CENAPS Corporation, Hazel Crest, Illinois, 1985.

[12] Gorski, Terence T., Passages Through Recovery:  An Action Plan for Preventing Relapse, Hazelden, 1989

[13] Prochaska, James O., Norcross, John C., & DiClemente, Carlo C., Changing for Good, Wiliam Morrow and Company Inc., New York, 1994

[14] Brown, Stephanie, Treating the Alcoholic: A Development Model of Recovery. New York, John Wiley & Sons, 1985.

[15] Marlatt, G. A. and Gordon, J. R., Eds.  (1988)  Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behavior.  New York:  Guilford Press

[16] 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

[17] Irvin, J.E., Bowers, C.A., Dunn, M.E., Wang, M.C.  “Efficacy of Relapse Prevention: A Meta-Analytic Review,” Journal of Consulting and Clinical Psychology, Source Id: 67(3):563-570, 1999

[18]  Gorski, Terence T,  The CENAPS Model Of Relapse Prevention Planning, In Daly, Dennis W. Relapse:  Conceptual, Research, and Clinical Perspectives, Hayworth Press, 1989 Pg. 153 – 161; the Journal of Chemical Dependency Treatment, Volume 2 Number 2, 1989.

[19]  Marlatt, G. A. and Gordon, J. R., Eds.  (1988)  Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behavior.  New York:  Guilford Press, pp. 351-416.

[20]  George, William H.,  Marlatt and Gordon’s Relapse Prevention Model:  A Cognitive-Behavioral Approach To Understanding And Preventing Relapse, Journal of Chemical Dependency Treatment, vol. 2, no. 2 (1989): 153-169.

[21]  Trotter, Caryl, Double Bind: Recovery and Relapse Prevention For The Chemically Dependent Sexual Abuse Survivor, Herald House/Independence Press, Independence, MO, 1992.

Positive Mental Attitude Plus

December 31, 2013

Don’t Worry – Be Positive

By Terence T. Gorski, Author
December 31, 2013

Positive mental attitude (PMA) is effective in many ways. There are limits to the effectiveness of positive thinking. It is not always enough to change deeply entrenched irrational core beliefs about self, others and the world that developed in early childhood. These core mistaken beliefs are often described using the idea of a  SCHEMA. When a core schema is challenged, it I feels like having a killer put a gun to our head and threaten to shoot. Our survival reactions kick in and our brains kick our body into action to get ready to fight or flee. These, of course are the classical fight or flight responses.

The consciously created positive thoughts are often unable to penetrate the survival responses (Fight, Flight, Freeze) that are activated in defense of our core beliefs.

Our core beliefs are developed in childhood to defend us from threats to our survival. Alfred Adler was the first to talk about the idea of core mistaken beliefs. Today, there is a method of therapy entirely devoted to identifying and changing core bore beliefs.

Our childhood beliefs have become the truth as we see t. As a result we defend these core irrational and destructive beliefs because we are firmly convinced that they are needed for survival.

Mindfulness meditation helps people to develop the skill of being detached and aware. As a result we can become aware of these core irrational beliefs about self, others, and the world without activating self-destructive survival behaviors driven by high stress. There are simple ways to get people into using mindfulness meditation.

Combining mindfulness meditation, which allows a detached awareness of emerging thoughts, without activating survival mechanisms, can add to the effectiveness of positive thinking and affirmations. Mindfulness meditation also stops the automatic self-talk, called rumination, driven by mistaken childhood beliefs from constantly running through our minds.

The final component is a learned system for emotional management and problems solving. A comprehensive system for managing thoughts and feelings and the core belies that drive them is described in the workbook entitled Cognitive Restructuring for Addiction.

These components can make an effective combined practice for recovery:
1. Positive (Rational) Thinking
2. Mindfulness Meditation
3. Emotional Management
4. Problem solving.

Mindfulness Made Simple

December 30, 2013

Mindfulness Can Be
A Brightly Colored Experience

By Terence T. Gorski, Author
December 30, 2013 

See the related blogs:
Stress Self-Monitoring and Relapse ,
The CENAPS Model and Mindfulness in Relapse Prevention,  and
Mindfulness Made Simple.

Meditation has been a part of the GORSKI-CENAPS Model since it was developed in the late 1970’s. In the 1970’s meditation was first being introduced and was controversial in the field of addiction and psychotherapy. Some viewed it as a fringe science. The first recognition that meditation could be helpful was in the form of relaxation training, which used a wide variety of relaxation methods whose origin was in meditation.

Mindfulness is a form of meditation that, if used consistently, becomes a habit of mind.  It stops, for a moment the ever-present chattering within our minds. As we detach and let go of thinking, we stop disrupting the balance of stress chemicals in the brain. We allow the ripples in the pool of emotions to settle as we release and relax. The letting go calms us. Our mind can become like a clear pool instead of a stormy sea of emotion.

In this blog I explain a simple process of Mindfulness Meditation that many people find helpful. It is the system I personally use. As with all things, it works better for me on some days than on others. I hope you will find it helpful.

Mindfulness #1: Looking Within & Seeing What I Saw

I heard about Mindfulness Meditation and decided to give it a try. I sat in a quiet place and just looked within my mind to see what I saw. I found that there was this constant stream of words running through my mind that blinded me to everything else I was experiencing. This stream of words is called: SELF-TALK. Knowing that my self-talk is there and running wild and chattering endlessness in my mind was a first step.

Mindfulness #2: Setting a Meditation Schedule

I decided that I would do five minutes of mindfulness meditation, four times a day, when I awoke in the morning, at midday, in the early even, and at night. I used these four of five-minute breaks to look silently within – not to know, but for a moment to let go of knowing and the need to know. I was developing the art of doing nothing. No big deal, right? I was amazed at how often I forgot my plan, or talked myself out of doing it because more important things came up!

Mindfulness #3: Allowing the Thoughts to Stop

To get my thoughts to stop, even for a moment, I used the idea of noticing the thoughts, detaching from them and letting them be. I then imagining the flow of words in my mind was like a long freight train. I just watched as the train and allowed the cars to slowly coast to a stop. I experiment with letting go by using different images like drifting in a gentle stream, rocking slowly on a swing.  I focused on slowly breathing in and out. I let go, and each time I took it back, I said “that’s interesting” and then I let go and started again to drift.

Mindfulness #4: Passive Awareness

I use “Passive Awareness” like this:

(1) I say to myself “I am not my thoughts, I am the one who thinks my thoughts;
(2) I detach from my thinking and imagine my thoughts passing by on a black board or movie screen;
(3) I peacefully observe my thoughts and let them go.
(4) I put no effort into this. I challenge my thoughts. I don’t judge, dismiss or change them. I just notice my thoughts, whisper to myself the words release and relax, and then I let the thoughts drift by. I call this letting go.
(5) I focus on my slow rhythmic breathing.
(6) I suspend judgment. I just notice and let them go.
(6) I say the words “release and relax” and allow my mind to slowly settle itself.

Mindfulness #5: Dealing With Distracting Thoughts and Feelings

When I noticed the thoughts coming back into my mind, I say to myself: “Ah! The thoughts are back! Isn’t that interesting. I’ll just watch them for a while and let them go as I did before.  If I noticed a feeling like fear rising up, I say to myself: “Isn’t that interesting, I am becoming afraid. I’ll observe that feeling for a while and let it go!” In becoming passive and detached I keep changing my focus back to my slow rhythmic breathing.

Mindfulness Made Simple -A Formula for Dealing With Distractions

The formula is: “I am now experiencing _____. Isn’t that interesting. I’ll observe it in a detached way, quietly name it, and let it go.” Next I say to myself: “I am breathing and notice my slow rhythmic breath as I slowly inhale, hold for a moment, slowly exhale, hold for a moment, and repeat the process while passively noticing what my brain/mind is doing in the background of my consciousness. I say: “Let go! Release and Relax.”

This is an overly simplistic system for mindfulness. It strips away a lot of the jargon and mystique that made meditation difficult for me to practice. This simplified system has worked for me and many other people I shared it with. I hope it can help you.

The Magic Circle Relaxation Method




How To Develop A Relapse Prevention Plan

December 30, 2013

RP_CENAPSBy Terence T. Gorski
September 25, 1989, Original Publication  

Introduction, December 31, 2013: People who relapse aren’t suddenly taken drunk.  Most experience progressive warning signs that reactivate denial and cause so much pain that self-medication with alcohol or drugs seems like a good idea.  This is not a conscious process.  These warning signs develop automatically and unconsciously.  Since most recovering people have never been taught how to identify and manage relapse warning signs, they don’t notice them until the pain becomes too severe to ignore.

Relapse prevention therapy (RPT) was originally developed for use with chemically dependent people. Over the past decades it has been used extensively with other self-defeating repetitive behaviors and behavioral addictions. Dr. Alan Marlatt developed a cognitive-behavioral model of relapse prevention. At the same time Terence T. Gorski developed a nine-step relapse prevention model that closely paralleled Marlatt’s work. It was different in that it focused more heavily upon early warning sign of relapse, a more user-friendly cognitive restructuring model for relapse warning signs and high risk situations. The relapse prevention workbooks were widely used because they were effective in counseling settings. They were developed and revised with the extensive feedback from addiction professionals and recovering people. The characteristics of an effective treatment manual are described in Treatment Manuals That Work. The Relapse Prevention Workbooks were also popular because they were part of a series of workbooks that shared the same no-nonsense language and the same core cognitive restructuring process. Gorski’s model was chosen by SAMHSA as the basis of Tap 19: Relapse Prevention with Chemically Dependent Criminal Offenders, Counselor’s Manual and the basic manual has been translated in over seven languages.

There are nine steps in learning to recognize and stop the early warning signs of relapse.

Step 1:  Stabilization
Step 2:  Assessment
Step 3:  Relapse Education
Step 4:  Warning Sign Identification
Step 5:  Warning Sign Management & Coping Strategies
Step 6:  Recovery Planning
Step 7:  Inventory Training
Step 8:  Family Involvement

Step 9:  Follow-UP

The application of some of these steps can be illustrated by reading the story of Jake, a 23 year-old chronic relapser on the following pages.

Step 1:  Stabilization

Relapse prevention planning probably won’t work unless the relapser is sober and in control of themselves.  Detoxification and a few good days of sobriety are needed in order to make relapse prevention planning work.  Remember that many patients who relapse are toxic.  Even though sober they have difficulty thinking clearly, remembering things and managing their feelings and emotions.  These symptoms get worse when the person is under high stress or is isolated from people to talk to about the problems of staying sober.  To surface intense therapy issues with someone who has a toxic brain can increase rather than decrease the risk of relapse.  In early abstinence go slow and focus on basics.  The key question is “What do you need to do to not drink today?”

Step 2:  Assessment

The assessment process is designed to identify the recurrent pattern of problems that caused past relapses and resolve the pain associated with those problems. This is accomplished by reconstructing the presenting problems, the life history, the alcohol and drug use history and the recovery relapse history.

By reconstructing the presenting problems the here and now issues that pose an immediate threat to sobriety can be identified and crisis plans developed to resolve those issues.

The life history explores each developmental life period including childhood, grammar school, high school, college, military, adult work history, adult friendship history, and adult intimate relationship history.  Reviewing the life history can surface painful unresolved memories.  It’s important to go slow and talk about the feelings that accompany these memories.

Once the life history is reviewed, a detailed alcohol and drug use history is reconstructed.  This is be done by reviewing each life period and asking four questions: (1) How much alcohol or drugs did you use?  (2) How often did you use it?  (3) What did you want alcohol and drug use to accomplish? and  (4) What were the real consequences, positive and negative, of your use? In other words, did the booze and drugs do for you what you wanted it to do during each period of your life?

Finally, the recovery and relapse history is reconstructed. Starting with the first serious attempt at sobriety each period of abstinence and chemical use is carefully explored.  The major goal is to find out what happened during each period of abstinence that set the stage for relapse.  This is often difficult because most relapsers are preoccupied with their drinking and drugging and resist thinking or talking about what happened during periods of abstinence.

Comprehensive assessments have shown that most relapsers get sober, encounter the same recurring pattern of problems, and use those problems to justify the next relapse.  As one person put it “It is not one thing after the other, it is the same thing over and over again!”

A 23 year old relapser named Jake reported drinking about a six-pack of beer every Friday and Saturday night during high school.  He did it in order to feel like he was part of the group, relax and have fun.  at that stage in his addiction the beer did exactly what he wanted it to do.

That all changed when Jake left school and went to work as a salesman.  He had to perform in a high-pressure environment and felt stressed.  The other salesmen were competitive and no matter what he did they wouldn’t let him belong.  He began drinking bourbon every night to deal with the stress.  He wanted to feel relaxed so he could cope better at work.  He consistently drank too much and woke up with terrible hangovers that caused new problems with his job.

Every time Jake would attempt to stop drinking he would feel isolated and alone and become overwhelmed by the stress of his job.  Even when with others at Twelve Step Meetings he felt like he didn’t belong and couldn’t fit in.  As the stress grew he began to think “If this is sobriety who needs it?”  Each relapse was related with his inability to deal with job related pressures.

By comparing the life history, the alcohol and drug use history, and the recovery relapse history Jake could see in a dramatic way the recurrent problems that caused him to relapse. The two major issues were (1) the need to drink in order to feel like he belonged and (2) the need to drink in order to cope with stress.

It wasn’t surprising that Jake discovered that during every past period of abstinence he became isolated, lonely and depressed.  The longer he stayed sober the worse it got.  The stress built up until he felt that if he didn’t take a drink to relax he would go crazy or collapse.

Step 3:  Relapse Education

Relapsers need to learn about the relapse process and how to manage it.  It’s not a bad idea to get their family and Twelve Step Sponsors involved.  The education needs to reinforce four major messages:  First, relapse is a normal and natural part of recovery from chemical dependence.  There is nothing to be ashamed or embarrassed about.  Second, people are not suddenly taken drunk.  There a progressive patterns of warning signs that set them up to use again.  These warning signs can be identified and recognized while sober.  Third, once identified recovering people can learn to manage the relapse warning signs while sober. And Fourth, there is hope.  A new counseling procedure called relapse prevention therapy can teach recovering people how to recognize and manage warning signs so a return to chemical use becomes unnecessary.

When Jake entered relapse prevention therapy he felt demoralized and hopeless.  That began to change when he heard his first lecture that described the typical warning signs that precede relapse to chemical use.  He felt like someone had read his mail.  “Since someone understand what causes me to get drunk,” he thought, “perhaps they know what to do in order to stay sober.

Step 4:  Warning Sign Identification

Relapsers need to identify the problems that caused relapse.  The goal is to write a list of personal warning signs that lead them from stable recovery back to chemical use.

There is seldom just one warning sign.  Usually a series of warning signs build one on the other to create relapse.  It’s the cumulative affect that wears them down. The final warning sign is simply the straw that breaks the camel’s back.  Unfortunately many of relapsers think it’s the last warning sign that did it. As a result they don’t look for the earlier and more subtle warning signs that set the stage for the final disaster.

When Jake first came into relapse prevention therapy he thought that he was crazy.  “I can’t understand it,” he told his counselor, “Everything was going fine and suddenly, for no reason at all I started to overreact to things.  I’d get confused, make stupid mistakes and then not know what to do to fix it.  I got so stressed out that I got drunk over it.”

Jake, like most relapsers, didn’t know what his early relapse warning signs were and as a result didn’t recognize the problems until it was too late.  A number of procedures are used to help recovering people identify the early warning signs relapse.

Searching for your own warning signs

Most people start by reviewing and discussing The Phases And Warning Signs Of Relapse (available from Independence Press, PO Box HE, Independence MO 64055, 1-800-767-8181).  This warning sign list describes the typical sequence of problems that lead from stable recovery to alcohol and drug use.  By reading and discussing these warning signs relapsers develop a new way of thinking about the things that happened during past periods of abstinence that set them up to use.  They learn new words with which to describe their past experiences.

After reading the warning signs they develop an initial warning sign list by selecting five of the warning signs that they can identify with.  These warning signs become a starting point for warning sign analysis.  Since most relapsers don’t know what their warning signs are they need to be guided through a process that will uncover them.  The relapser is asked to take each of the five warning signs and tell a story about a time when they experienced that warning sign in the past while sober.  They tell these stories both to their therapist and to their therapy group.  The goal is to look for hidden warning signs that are reflected in the story.

Jake’s Relapse Warning Signs

Jake, for example, identified with the warning sign “Tendency toward loneliness.”  He told a story about a time when he was sober and all alone in the house because his wife had left with the children.  “I felt so lonely and abandoned, he said.  I couldn’t understand why she would walk out just because we had a fight.  She should be able to handle it better than she does.”

The group began asking questions and it turned out that Jake had frequent arguments with his wife that were caused by his grouchiness because of problems on the job.  It turned out that these family arguments were a critical warning sign that occurred before most relapses.  Jake had never considered his marriage to be a problem, and as a result never thought of getting marriage counseling.

Jake had now identified three warning signs:  (1) the need to drink in order to feel like he belonged, (2) the need to drink in order to cope with stress, and (3) the need to drink in order to cope with marital problems.  In order to be effectively managed each of these warning would need to be further clarified.

I then had Jake to write these three warning signs using a standard format and identify the irrational thoughts, unmanageable feelings and self-defeating behavior that accompanied each.  He wrote:

(1) I know I am in trouble with my recovery when I start feeling lonely and unable to fit in with other people;

When this happens I tend to think that I am no good and nobody could ever care about me.
When this happens I tend to feel lonely, angry and afraid.
When this happens I have an urge to hide myself away so I don’t have to talk with anyone.

(2) I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress;

When this happens I tend to think that I need to try harder in order to get things under control or else I will be a failure.
When this happens I tend to feel humiliated and embarrassed.
When this happens I have an urge to  drive myself to keep working even thought I know I need to rest.

(3) I know I am in trouble with my recovery when I irrationally angry at my wife.

When this happens I tend to think that I’m a terrible person for treating her that way, but a part of me believes she deserves it.
When this I happens I tend to feel angry and ashamed.
When this happens I have un urge to forget that the incident ever happened, put it behind us and get on with our marriage.

Step 5:  Warning Sign Management & Coping Strategies

With this detailed description of the relapse warning signs Jake was ready to move on to the fifth step of relapse prevention planning, warning sign management.  Understanding the warning signs is not enough.  We need to learn how to manage them without resorting to alcohol or drug use.  This means learning nonchemical problem solving strategies that help us to identify high-risk situations and develop coping strategies.  In this way relapsers can diffuse irrational thinking, manage painful feelings, and stop the self-defeating behaviors before they lead to alcohol or drug use.

This is done by taking each relapse warning sign and developing a general coping strategy.  Jake, for example developed the following management strategy for dealing with his job related stress.

Jake’s Warning Sign
I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress.

General Coping Strategy
I will learn how to say no to taking on extra projects, limit my work to 45 hours per week, and learn how to use relaxation exercises and meditation to unwind.

Matching Coping Strategies to Warning Signs

The next step is to identify ways to cope with the irrational thoughts, unmanageable feelings, and self-defeating behaviors that accompany each warning sign.  Jake developed the following coping strategies:

Irrational Thought:  I need to try harder in order to get things under control or else I will be a failure.
Rational Thought:  I am burned out because I am trying too hard.  I need to time to rest or I will start making more mistakes.

Unmanageable Feelings:  Humiliation and embarrassment.
Feeling Management Strategy:  Talk about my feelings with others.  Remind myself that there is no reason to embarrassed.  I am a fallible human being and all people get tired.

Self-defeating Behavior: Driving myself to keep working even thought I know I need to rest.
Constructive Behavior:  Take a break and relax.  Ask someone to review the project and see if they can help me to solve the problem.

Step 6:  Recovery Planning

Now Jake is ready to move unto the sixth step of recovery planning.  A recovery plan is a schedule of activities that puts relapsers into regular contact with people who will help them to avoid alcohol and drug use.  They must stay sober by working the twelve step program and attending relapse prevention support groups that teach them to recognize and manage relapse warning signs.  This is why I call relapse prevention planning a “Twelve Step Plus” approach to recovery.

Jake needed to build something into his recovery program to help him deal with job related stress.  He decided to enter into counseling with a counselor who specialized in stress management, understood chemical dependency and had a background as an employee assistance counselor.  By doing this Jake was forced to regular discuss his problems at work and review how he was coping with them.  By identifying job related problems early, he could prevent getting overwhelmed by small problems that became overwhelming.

Step 7:  Inventory Training

The seventh step is inventory training.  Most relapsers find it helpful to get in the habit of doing a morning and evening inventory.  The goal of the morning inventory is to prepare to recognize and manage warning signs.  The goal of the evening inventory is to review progress and problems.  This allows relapsers to stay anticipate high risk situations and monitor for relapse warning signs.  Relapsers need to take inventory work seriously because most warning signs are deeply entrenched habits that are hard to change and tend to automatically come back whenever certain problems or stresses occur.  If we aren’t alert we may not notice them until it’s too late.

Step 8:  Family Involvement

The eighth step is family involvement.  A supportive family can make the difference between recovery and relapse.  We need to encourage our family members to get involved in Alanon so they can recover from codependency.  With this foundation of shared recovery we can beginning talking with our families about past relapses, the warning signs that led up to them, and how the relapse hurt the family.  Most importantly we can work together to avoid future relapse.

If we had heart disease we would want our family to be prepared for an emergency.  Chemical dependency is a disease just like heart disease.  Our families’ needs to know about the early warning signs that lead to relapse.  They must be prepared to take fast and decisive action if we return to chemical use.  We can work out in advance, when we are in a sober state of mind, the steps they should take if we return to chemical use.  Our very life could depend upon it.

Step 9:  Follow-Up

The final step is follow-up.  Our warning signs will change as we progress in recovery.  Each stage of recovery has unique warning signs.  Our ability to deal with the warning signs of one stage of recovery doesn’t guarantee that we will recognize or know how to manage the warning signs of the next stage.  Our relapse prevention plan needs to be updated regularly; monthly for the first three months, quarterly for the first two years, and annually thereafter.

Originally Published In:  Alcoholism & Addiction Magazine: Relapse – Issues and Answers: Column 3:  How To Develop A Relapse Prevention Plan: By Terence T. Gorski, September 25, 1989, and updated regularly since that time.

About the Author

Terence T. Gorski is the President of the CENAPS Corporation a training and consultation firm specializing in relapse prevention, addictive relationships and treating chemically dependent ACA’s.  He holds a B.A. degree in psychology and sociology from Northeastern Illinois University and an M.A. from Webster’s College in St. Louis, Missouri.  He is a Senior Certified Addiction Counselor In Illinois.  He also contributes articles and interviews to major magazines, acts as a consultant to the health care industry, and conducts workshops in the U.S., Canada, and Europe.

Some of his books include Passages Through Recovery, Staying Sober: and Relapse Prevention for African Americans. These and many more are provided in our Recovery Bookstore under the heading “Relapse Prevention. For more information about his leading techniques used by some of the nation’s top rehabilitation facilities or to  enroll in one of his training programs, you may also visit his site directly at

Treatment Manuals That Work

December 30, 2013

Well designed treatment manuals
make recovery easier for everyone.

By Terence T. Gorski, Author
December 30, 2013

Many clinicians feel frustrated when they are “mandated” to use TREATMENT MANUALS with patients. Here are some points to consider:

1. Treatment manuals are either well designed or poorly designed. WELL DESIGNED MANUALS are easy to use, present exercises in a logical series of progressive skill-building steps, and have exercises to practice the skills in real-life situations.


2. The language in well-designed manuals avoids both “PSYCHO-BABBLE”, highly technical psychological language, and RECOVERY TALK, the heavy use of 12-Step language, slogans, and platitudes.

Therapists require training in how to use a manual in individual and group therapy. They also need experience in treating the addiction or related problems that is the focus of each manual. Here are the basic steps that therapists need to take to become proficient in “manualized” treatment:

Step 1: Understand the therapeutic purpose of the workbook and the goal of each exercise. Review the way the sequence of information, questions, and suggested activities are used . Use each exercise to take the patient on a journey of new understanding.

STEP 2: Take ownership of the manual content by integrating it into your own personal style and be prepared to clarify or elaborate on the concepts in the manual in words, ideas, and examples that you are comfortable with.

STEP 3: Adapt the use of the manual to the structure and needs of the program you are working in.

STEP 4: Adapt the use of the manual to the needs of each individual patient. The key question is: Does the manual  meet the needs of the patients? If yes, the manual can be a valuable addition to traditional psychotherapy. If no, don’t use the manual.

Using a manual that does not address the important problems of a patient is the equivalent of giving patients the wrong medications. DON’T DO IT! Match specific manuals to the individual needs and treatment plans of patients.

It is important for therapist to work with management when adapting the use of manuals for use within a specific clinical program. How clinical staff negotiate with management for the appropriate use of treatment manuals is critical. Some negotiation styles cause head-to-head conflicts and power struggles. Others invite a collaborative process of evaluation that looks for the most effective way to use the manual with an individual patient.

Here are ways that the use of the manual can be adjusted to meet patient needs:

1. Sometimes the content of the manual needs to be delivered in smaller or bigger “chunks” of information that fit the patient’s cognitive ability and learning style.

2. Sometimes patients will respond better if the information is delivered in a different order. Feel free to adjust the sequence to match the patient’s interests and needs.

3. Skip sections of the manual that don’t fit the needs of the patient, or repeat knowledge and skills the patient already has.

4. The manual can be augmented with other handouts and exercises that can powerfully adjust the clinical approach guided by the manual.

5. Manuals are designed to have the exercises completed as homework assignments. These assignments help patients prepare for individual, group, and psycho-educational sessions.

6. When patients present workbook assignments in groups, it is usually not a good idea to have patients read their answers to each questions. This puts people to sleep. It is better to have a group reporting form that asks patients to answer these questions:

(1) What’s the most important thing that you learned from doing the exercise?

(2) What parts of the exercise were most difficult for you to complete?

(3) What parts do you want the group to help you understand and apply to your own situation?

(4) What can you do differently in your recovery as a result of what you learned by completing this exercise?

(5) How can what you learned help you to move forward in your recovery plan?

Treatment manuals provide guidelines and tools for patients to move forward in therapy. When used properly they can enhance the treatment process. Manuals ARE NOT straight jackets that restrict creativity and clinical reasoning.

Most importantly, treatment manuals don’t DO anything. The clinician who understands their value can use them to make their job easier and to improve the effectiveness of treatment. Well designed treatment manuals help therapists accomplish more while investing less time and energy.

Here are some well-designed and useful manuals to use in addiction treatment and relapse prevention:


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