Cognitive Restructuring: Why It Works With Addiction

June 8, 2014

Addictive ThinkingBy Terence T. GorskiAuthor

Abstract: This detailed blog by Terence T. Gorski explains the biopsychosocial factors in chemical and behavioral addictions; describes how cognitive restructuring can change addictive thoughts, feelings, and behaviors; and shows how the process can provide organization to the treatment/recovery process while improving the collaboration between the addiction professional and the recovering person. References are provided that show that Cognitive Behavioral Therapy (CBT), the core method upon which Cognitive Restructuring for Addiction is based, is an evidence-based practice.

COGNITIVE means information processing in the brain.

RESTRUCTURING means changing how information is processed by the brain.

ADDICTION, described in DSM IV as Substance Use disorders), is described in DSM 5 as addictive disorders and has been expanded to include: Chemical Addictions (alcohol and other mind altering drugs of abuse); and Behavioral Addictions (gambling and other forms of compulsive mood altering behaviors).

All addictive disorders share a common set of similarities which include:

  • Addictive Beliefs (Addictive use is an effective way to stop my pain and solve my problems);
  • Automatic repetitive addictive thinking patterns (often called addictive rumination) that is difficult to self-regulate;
  • Obsession (Out-of-control thinking about the addiction);
  • Compulsion (the strong irrational urge to engage in addiction seeking behavior and addictive use);
  • Craving (A powerful urge based in a psychobiological response to cues or triggers that activates a powerful urge ton use in order to normalize the uncomfortable feelings caused by the biological symptoms of the craving);
  • Loss of Control (A pattern of compulsive use making it difficult self regulate the quantity, frequency, or duration of addictive use episodes);
  • Secondary life and health problems caused by the loss of control. These tend to be related to the specific addictive release being used); and
  • Continuation of use in spite of adverse consequences and a subjective desire to stop and reduce the use.

Each specific addictive disorder that is organized around a specific drug of choice or behavior of choice has unique differences that need to be considered in treatment. An alcoholic who does not use prescription or illicit drugs will participate in a different addictive culture and have adaptations in their addictive thinking that accommodates the focus of their addiction. The same is true of Prescription drug Addicts who don;t use illicit drugs, illegal drug users also involved in criminal drug-centered culture, gamblers, compulsive over-eaters, etc.

As a result, the above symptoms of addiction are caused by:

  • A complex individualized (idiosyncratic) biopsychosocial responses in each addicted person;
  • The specific substance or behavior that is the primary source of addictive release;
  • The social and cultural reaction to the use, abuse, and addiction to the specific substance or behavior.
  • The degree of addictive brain dysfunction;  and
  • The unique information processing style of the  addict originating in the family of origin and influenced by social and cultural experiences.

These differences, however, are accompanied by a cognitive or information processing styles that are similar in all addicted people and create:

  • Addictive Beliefs/Automatic Thinking based upon the mistaken belief that “addictive use will take away my pain and solve my problems!”
  • Craving which is a strong irrational urge to use addictively in spite of good reasons not to. Cravings usually do not result from rational decision-making. They are usually activated by environmental cues or triggers. and
  • Habitual addiction-seeking behaviors, activated by the cue/trigger and acted out automatically and unconsciously. These addiction seeking behaviors are known as early relapse warning signs. Acting them out puts addicts into high-risk situations that surround then with people, places, and things that will encourage and support their use of alcohol and other drugs.

Cognitive restructuring is a proven method for:

1. Stopping addictive thinking and challenging addictive beliefs;

2. Managing craving;

3. Stopping or redirecting addiction-seeking behaviors;

4. Avoiding or effectively managing high risk situations;

5. Having a well-rehearsed emergency plan to stop addictive use should it begin; and

6. Using a debriefing process (sometimes called a relapse autopsy) to examine past relapse episodes and near-miss experiences in order to learn how to avoid or effectively manage similar situations in the future.

Cognitive restructuring for addiction, which is at the core of Relapse Prevention Therapy (RPT) is a core set of principles, practices, tools, and skills that can be used to enhance recovery and prevent relapse. When used effectively these principles and practices teach people:

  • How to change their thoughts, feelings, and behaviors in ways that eliminate or reduce craving and drug seeking behavior.
  • How to manage high risk situations;
  • How to find a sense of meaning and purpose in recovery that is note satisfying than acting out an addictive lifestyle.

The Cognitive Restructuring for Addiction Workbook contains a series of clear, simple, and effective exercises that can enhance recovery while breaking the cycle of relapse.

The exercises in the workbook can be applied to a wide variety of chemical and behavioural addictions as well as other problems involving the repetitive and habitual use of a specific self-defeating behavior.

The underlying cognitive restructuring process is the same. Additional information that is specific to unique addictive behaviors can increase effectiveness. The manual is based upon evidenced-based Cognitive Behavioral Therapy (CBT) principles and practices that are effective with addiction, depression, PTSD, and a wide variety of other disorders that are lifestyle-related and subject to periodic regression or relapse. (CBT and related therapies are documented as evidence-based practices by SAMHSA-NREPP.

A small investment in this inexpensive workbook can:

  • Organize and structure the recovery/therapy process;
  • Provide home-work assignments that increase progress; and
  • Demonstrate the use of evidence-based practices.

Most importantly, the proper use of the exercises in this workbook can literally make the difference between helping people to move forward in recovery, or to slide backwards into addictive use and the horrible damage than can be caused.

Click here to order: THE COGNITIVE RESTRUCTURING FOR ADDICTION WORKBOOK. This small investment could save you sobriety.

A Home Study that awards CEU’s for studying this workbook are available: email: or visit Gorski-CENAPS Home Studies 


Post Acute Withdrawal: Survey Confirms PAW

December 23, 2013

PAWS affects 91% of addicts

The first-ever survey on Post Acute Withdrawal Syndrome polled more than 1200 drug addicts and alcoholics and resulted in some fascinating and troubling statistics.  For instance, nearly 91% of addicts will suffer from the condition, but just more than 1 in ten will actually get help or treatment for it.  In reality, most addicts have probably never heard of the condition and organizers of the 2013 Post Acute Withdrawal Survey hope to change that.

The following press release was published in PRWeb on 09/10/2013 describing the survey and its results in detail:

Survey Showing 91% of Addicts Face Post Acute Withdrawal Published by Recovery First, Inc.

In the first survey on Post Acute Withdrawal Syndrome, results indicate that 9 out of 10 addicts suffer from the condition responsible for most cases of drug or alcohol relapse, but only 13% of addicts receive PAWS-focused treatment.

Ft. Lauderdale, FL (PRWEB) September 10, 2013

Despite widespread recognition as the leading cause of relapse among recovering addicts and alcoholics, few addiction treatment centers address Post Acute Withdrawal Syndrome. But in a large survey conducted by the nation’s leading expert on PAWS, the results indicate that this lack of focus could be largely responsible for the revolving door nature of most drug rehab centers.

James F. Davis, CAS, is a Board Certified Interventionist and an authority on Post Acute Withdrawal. He’s also the founder of a large drug treatment center in South Florida. When he learned that his treatment center was one of just a handful in the country that treats Post Acute Withdrawal Syndrome, he set out to do something about it.

Davis founded the website and spent 6 months polling recovering drug addicts and alcoholics in the first-ever survey to collect information about PAWS.

Now Davis says the survey indicates that the drug addiction treatment industry needs to undergo a transformation.

“What we found is that very few treatment centers address Post Acute Withdrawal, and those that do approach the condition rather cursorily. As a consequence many addicts leave rehab sober but quickly relapse when their PAWS symptoms go untreated.”

Davis went on to explain that PAWS is the most critical and persistent problem facing people in recovery.

According to the Wikipedia entry for the condition, Post Acute Withdrawal Syndrome;

“The syndrome may be in part due to persisting physiological adaptations in the central nervous system manifested in the form of continuing but slowly reversible tolerance, disturbances in neurotransmitters and resultant hyper excitability of neuronal pathways.”

But Davis claims that there’s a lot more to this relapse-causing condition than neuronal disturbances alone:

“PAWS is caused by changes in neurons as a result of prolonged substance abuse, but this is just one piece of the puzzle. Other forces are at work, including the backfiring of evolutionary survival mechanisms and a powerful conditioned response similar to that experienced in the case of Pavlov’s drooling dogs.”

Davis is in the process of publishing a book which explains his theories on PAWS in expansive detail. The book is based in part on the survey results, which shows that of the 91% of recovering addicts afflicted with the condition, more than 25% will experience symptoms lasting longer than 2 years.

Other key findings in the Post Acute Withdrawal Survey include:

  • *71% of survey respondents believe that PAWS has led to one or more drug/alcohol relapses
  • *AA & NA Meetings are the favored method of treatment for symptoms related to PAWS
  • *Most respondents do not treat symptoms with medication
  • *Most physicians are not familiar with PAWS
  • *”Stress” and “Emotional Symptoms” were chosen by nearly half of all respondents as the primary symptom types leading to relapse
  • *61% of those polled had attended an inpatient drug treatment program, with 34% of those failing or quitting the treatment early
  • *28% of respondents have relapsed 3-6 times, with another 20% relapsing more than 10 times

At Davis’ clinic in South Florida, Post Acute Withdrawal is a primary focus of treatment. Recovery First, Inc. was founded by Davis more than a decade ago, and in that time he’s helped thousands of addicts and alcoholics achieve sobriety. By addressing the condition on a national level, Davis hopes to bring awareness to both the medical community and the general public.

“Many people still view addiction as a matter or poor morals, weak will power or some other character defect. But the fact of the matter is that this is a progressive neurological disease that if left untreated invariably leads to death. Many of these deaths occur during a relapse episode caused by PAWS. This means that understanding this inactive state of addiction is critical in order to save lives, and that’s where the survey comes in. By distributing these troubling results, we hope to transform the way we treat addicts.  The traditional focus has been to get addicts clean and get them out the door and into some support [networks], but this method does not address the fact that people in recovery will experience severe withdrawal-like symptoms for months after rehab. Without a plan to identify and manage PAWS symptoms, relapse is highly likely for people in the early stages of recovery.”

According to an astonishing number of forums, chats, blog posts, articles and recovery communities, the symptoms of PAWS include cognitive impairment, balance and coordination problems, wild emotional disturbances, sexual dysfunction, communication and socialization impairment and a wide range of physical ailments like headaches and sleep disturbances.

However, the primary symptom that most people in recovery report is a profound, often uncontrollable urge to use drugs or drink again despite devastating consequences.

Preventing relapse is the singular focus at Recovery First, Inc. – the leading sponsor and driving force behind the 2013 PAWS Survey. Interestingly, when James F. Davis, CEO speaks about addiction, recovery and relapse, he isn’t just speaking from a professional standpoint. 32 years ago he was severely addicted to cocaine and had been nursing a lifelong problem with alcoholism that almost killed him. Now he says his mission is to ensure that other addicts don’t travel a similar path.

Eric Oakes, LCSW and chief clinician at Recovery First, agrees that treatment of Post Acute Withdrawal is the most effective method of helping addicts avoid a relapse that could lead to imprisonment, illness or death;

“It’s not over when an addict or alcoholic leaves rehab, and this is where most treatment centers fail. According to the PAWS survey, the majority of people in recovery experience the most debilitating symptoms with the most likely propensity to relapse within 6 months or less of completing a rehab program. If we don’t prepare them for this, we have failed them as treatment providers.”

The Post Acute Withdrawal survey is a 20-question survey that polled 1,246 addicts and alcoholics over the course of more than 6 months. The entire survey including raw data, formal results and graphic representations can be found on the following URL: Davis, Recovery First, Inc. and have given public permission for all survey results and data to be republished or used for any purpose with proper attribution.

Plans to broaden the survey with questions related to specific drugs of abuse and how those symptoms might compare with other substances are in development. An updated version of the PAWS survey will be available in early October 2013.

This press release has been republished from PRWeb:

Social Support In Recovery – An Important Relapse Prevention Tool

December 3, 2013

By Terence T. Gorski

The Importance of Good Support Systems in Sobriety

 wrote an interesting article for Psych Central on The Importance of Good Support Systems in Sobriety. This article stirred up some ideas that I wanted to share. I also wanted to add to the excellent ideas that she presented.

Addiction is a biopsychosocial illness that is chronic, lifestyle-related, and relapse prone. The pathway to relapse is often marked by high stress, lack of social support for people who understand addiction, and easy access to high risk situations where there is ready availability to the drug of choice, social support for using, and isolation from people who are part of the recovery network. Once the social accountability factor is recovery is gone, the addictive mind of the addict comes into play and go wild romping in the fields of fantasy with alcohol and drug users.

Recovery is not just an individual experience. Because human being are social animals, we need to find other people who can support us in living a sober and responsible life. In an addiction centered culture that is not always easy. Most people are either addicted themselves or support the addictive cultures that surround us.

Recovery requires communication and feedback. We need to be around people who will tell us the truth in a helpful way that will allow us to hear what we are saying and invite us into a conversation. Most people who have not been in recovery get threatened by this level of honest or just don’t get why it’s important. After all, it is hard to fit in a good 10th step inventory (taking a daily review of what happened and correcting things that didn’t go well) while you’re in traffic with a friend rushing to the Casino getting ready for a hot date with the sixth stranger this week.

This is where recovery support groups, many built around the 12-Steps of AA, provide an important social outlet. twelve step programs guidelines (in the form of the 12-Steps), organizational guidelines for running coordinating groups (The 12-Traditions), and a solid and consistent social structure based around regular meetings, sponsorship, and mutual support. There is a rich a varying community of sober and responsible people from all walks of life with a wide variety of interests. It is a sober social network par excel lance.  Other support groups such a Women for Recovery and SMART Recovery are also available in manage communities. The Self-Help Group Source-book On-line references over thirty support groups for alcoholism and over 1,100 for just about every major lifestyle related problem that people experience.

Avoid Relapse By Developing A Sober Social Network.

 Having a network of people striving to live a sober and responsible life provides social options. It give us a place to look for people who are also building a life that is not centered around alcohol and other drugs. AS these new sober and responsible relationships begin to form, we feel less of a need for out old buddies that we used to drink and use drugs with. It also allows you to change relationships with codependents who have enabled you ongoing addiction.

The people you encounter in 12-step and other support groups are, like you, actively working toward a healthy life and using the tools necessary to stay clean. Associating with other sober people helps you avoid triggers and remain focused on maintaining your sobriety.

As with any important life change, the road to recovery is not always easy. Rather, as you continue to work on your recovery, you are likely to encounter many obstacles and challenges. A sober support group gives you the opportunity to talk through challenges.

Just as unhealthy people can drive you to use drugs and alcohol, a sober support group can help create pressure to make healthy choices. Attending meetings on a regular basis and maintaining a consistent dialogue with your sponsor means knowing that there are a great number of people who do not want you to relapse. This type of pressure can be very helpful as you work to stay clean.

They provide a lifeline during difficult times

Cindy Nichols says this very well in her article: “All recovering addicts face triggers throughout all stages of sobriety. Having access to a sponsor and a group of people you can turn to when you are tempted provides a healthy alternative to succumbing to triggers.”

Cindy also describes the role a sober social network can have in times of trouble or crisis: “Life is full of unplanned events. There is no telling when you may face anger, sadness, or stress because of circumstances that are outside of your control. As you become accustomed to dealing with these feelings in a constructive way, you continue to strengthen your ability to maintain your sobriety, regardless of what life throws at you.”

In working with relapse prone addicts for over forty years, one issue remains constant: those who can develop sober and responsible relationships and learn how to give and receive help are more likely to stay in long-term recovery that those who are isolated or stay connected with their old friends who are heavy drinkers and drug users. Stay sober.

The details of addiction and how to develop a solid recovery plan including sober social networking is explained in the book: Straight Talk About Addiction. 


Use No-nonsense Recovery Methods That Work


Cognitive Impairment and Recovery From Alcoholism

April 30, 2012

Introduction by Terence T. (Terry Gorski)

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

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

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

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

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

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

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

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

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

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

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

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

National Institute on Alcohol Abuse and Alcoholism

Alcohol Alert, No. 53 – July 2001

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

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

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

Cognition and Alcohol

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

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

How Much Is Too Much?

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

Tracking Structural and Functional Brain Abnormalities

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

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

Understanding the Basis of Cognitive Impairment

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

Is Impairment Reversible?

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

Rewiring Brain Networks

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

Cognitive Function and Alcoholism Treatment

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

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

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

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

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


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

Helping Characteristics

April 29, 2012
By Terence T. Gorski –

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

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

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

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

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

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

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

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

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

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

Confrontation, Self-Exploration, and Helping Characteristics

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

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

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


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

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

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

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

Anderson’s study looked at the relationship between:

(1) Th number of times the therapists used CONFRONTATION

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

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

HYPOTHESIS: The hypothesis was that:

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

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


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

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

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

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

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

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

Brain Disease – Expanding Into A Unified Model

April 29, 2012

By Terence T. (Terry) Gorski

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

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

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

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

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

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

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

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

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

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

~ Terry Gorski  via

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Stress Self-Monitoring and Relapse

April 27, 2012

By Terence T. Gorski 

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

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

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

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

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

The Stress Thermometer

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

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

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

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

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

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

Traunatic Stress: Level 10 Plus

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