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: tresa@cenaps.com or visit Gorski-CENAPS Home Studies 

 


Hitting Bottom and Detaching With Love

April 30, 2014
Up From Mud

Drowning In The Mud Of Addiction

By Terence T. Gorski, Author

People tend to get sober in their own time and in their own way. The world is loaded with codependents who destroyed their lives trying to get the addict they loved into recovery. Despite decades of perfecting the technique, professional interventions only result in the addict entering treatment in 80% of the cases. Sometimes the attempted intervention has the reverse effect, driving the addict farther away and deeper intone their addictive lifestyle.

Much of what we call “hitting bottom” or “getting sick and tired of being sick and tired” results from a chance convergence of immediate undeniable problems coupled with the offer of hope and a concrete opportunity to recover.

This doesn’t mean that you should not attempt to intervene with addicts you love. It just means that it is best to view intervention as an ongoing process of honest communication. These honest talks need to come from a posit of detached love. Active addicts are expert at detecting and thwarting the efforts of codependent who try, with the best of intentions, to control and manipulate them.

The most important rules in dealing with someone who is addicted are these:

  • Ÿ Get clear about what you will and will not tolerate and then set limits.
  • Ÿ Never make promises or threats that you are not willing or able to do.

Here are some more ideas to think about if someone you know and love is actively addicted: Keep loving them.

1. Keep loving them.

2. Remember their addiction is not about you.

3. Every addict has “teachable moments” but they are few and far between.

4. Choose carefully when you try to talk about getting help. In the aftermath of undeniable consequences when the person is sober and feeling remorseful is often the best time.

5. Work your anger out with your own therapist. Getting made at an addict just gives them the excuse to not take you seriously.

6. Detach with love. This means keep loving an caring but stop giving them resources that allow them to keep drinking and drugging.

7. Give them information about addiction and treatment/recovery resources.

8. Tell the truth and set clear boundaries calmly and firmly.

9. Remember, getting well is and always will be their choice. You can just make the choice easier by removing any support for their addiction and refusing to accept or enable any unacceptable behavior.

10. Loving an addicted family member is hard. It can make you a sick and codependent. Put yourself first. If you allow the addict to destroy you, it will make you part of the problem instead of being part of the solution.

The most important rules in dealing with someone who is addicted are these:

  • Ÿ Get clear about what you will and will not tolerate and then set limits.
  • Ÿ Never make promises or threats that you are not willing or able to do.

Ÿ Be consistent. Your behavior needs to be the stable point on the map of sober and responsible living.

These three rules are easy to understand buy incredibly difficult to put into action. So learn to be gentle with yourself. You wont be able to do it perfectly and you don’t need to.

Living with an addict is painful. So is setting boundaries and following through no matter what. Most of us need help and support to figure out what to do and to stand firm in the face of the out-of-control addiction of someone you love. It will take time and emotional work on your part to get prepared to detach with love while pointing the addict toward treatment/recovery resources. Don’t worry. The addiction probably won’t go away while you are learning to deal with it in ore effective ways.

It is hard detaching from an actively addicted person. There will come a point, however, when they will use any action you take as a part of their rationalization to keep using. Don’t take it personally. It is just what addicts do to everyone and anyone who tries to help.

Addicts do recover. They usually do it in their own time when the perfect storm of consequences start sinking their ship and the only rescue helicopter in sight is a recovery program.

This is a very difficult disease to have and just as difficult to live with.

If you are in recovery, don’t abandon those you love. When you get sober, please be aware that your friends and family may need not just your amends, but your help to get their health and their lives back.

Recovery is not just about the addict. It is about everyone who is affected by the addiction.

Check out Alanon and find a therapist knowledgeable in codependency.

LIVE SOBER – BE RESPONSIBLE – LIVE FREE

Gorski Books


PTSD and Addiction: A Cognitive Restructuring Approach

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

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.

PTSD ASSESSSMENT – A CRITICAL FIRST STEP

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.

ADDICTION ASSESSMENT – NOT A LUXURY, A NECESSITY

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.

PSYCHO-EDUCATION – TEACHING A LANGUAGE OF RECOVERY

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.

SURVIVORS – NOT VICTIMS

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.

GET PATIENTS SOME INITIAL RELIEF FROM PAIN

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.

THE LIFE AND SYMPTOMS HISTORY – A COLLABORATIVE APPROACH

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).

THE COMPREHENSIVE SYMPTOM LIST

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.

STRENGTH-BASED – WHAT ARE YOU DOING RIGHT

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?

THE IDEA OF PTSD SYMPTOM EPISODES

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.

SYMPTOM SELF-MONITORING

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.

FLASHBACKS – TEACHING PATIENT TO GET OUT SAFELY

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.

FINDING A SAFE PLACE INSIDE YOURSELF

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.

IMMEDIATE RELAXATION METHODS – CHOICE AND SAFETY

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.

SUPPORT NETWORKS 0 CRITICALLY IMPORTANT

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.

COGNITIVE RESTRUCTURING – TFUAR MANAGEMENT

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.

COGNITIVE RESTRUCTURING FOR PTSD

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 …

A SIMPLISTIC SKELETON OF A COMPLEX PROCESS 

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 GORSKI-CENAPS Model: A Comprehensive Overview

December 31, 2013

CENAPS_OverviewThe GORSKI-CENAPSâ Model Of
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 www.cenaps.com or E-mail: info@cenaps.com
Terry Gorski’s Blog: www.terrygorski.com; email: Terry@terrygoski.com 

© 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 (http://www.neuron.org/cgi/content/full/25/3/515/).

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 (http://ajp.psychiatryonline.org/cgi/content/full/157/11/1789).

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 (http://www.nap.edu/issues/17.3/leshner.htm)

Leshner A. I., “Science-Based Views of Drug Addiction and Its Treatment,” Journal of the American Medical Association 282 (1999): 1314­1316 (http://jama.ama-assn.org/issues/v282n14/rfull/jct90020.html).

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 (http://jama.ama-assn.org/issues/v284n13/rfull/jsc00024.html).

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) (http://165.112.78.61/PODAT/PODATindex.html).

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) (http://165.112.78.61/Prevention/Prevopen.html).

Nestler E. J., “Genes and Addiction,” Nature Genetics 26 (2000): 277­281 (http://www.nature.com/cgi-taf/DynaPage.taf?file=/ng/journal/v26/n3/full/ng1100_277.html).

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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

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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.


The Fog of Recovery

December 28, 2013
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The Deep Fog In Recovery

By Terence T. Gorski, Author
December 28, 2013

When a deep fog covers the land, it is good to walk carefully. When it invades the mind, we cannot trust even ourselves. In those times we need to reach out for help and accept the guidance from trusted friends and professionals.

The fog burns off under the bright sun of a sober and responsible life. We need to stay out in the light as we recover and avoid the shadows and dark places.

It also helps to eat healthy meals (low sugar, low-fat, complex carbs), supplement with B-complex vitamins and amino acid, meditate, and develop more effective life management skills.

When in a fog you need the help of others who know the way out. They can guide you to the bridge and the city beyond. No one can walk the path for you. You have to make the journey on your own two feet, taking one step at a time. You need to be willing to develop a lifeline of sober and responsible people who have traveled this path before and be willing to follow their lead.

The fog is caused by Post Acute Withdrawal (PAW), which results the long-term of after effects of brain dysfunction caused by active addiction. Post mean after, in this case, after acute withdrawal. A syndrome is a collection of symptoms. So post acute withdrawal is a collection of predictable symptoms that occur in addicted people after acute withdrawal subsides.

PAW can last three months or longer. The symptoms include difficulty in:
– Thinking clearly,
– Managing feelings and emotions,
– Remembering things,
– Sleeping restfully, and
– Problems with balance and physical coordination.

The symptoms are stress sensitive. This mean problems get more severe when under high stress.

A complete guide to Managing Post Acute Withdrawal (PAW), which is the major source of fog in the addict’s mind, is available in Terry Gorski’s Blog.
http://wp.me/p11fHz-eo

It is also explained in the Books
Staying Sober – A Guide for Relapse Prevention  and
Straight Talk About Addiction

LIVE SOBER – BE RESPONSIBLE – LIVE FREE

GORSKI BOOKSGORSKI TRAINING/CONSULTATION


The Gift

December 11, 2013

By Amber K Wilks
December 11, 2013

 Child_Poor_Girl“Children are beautiful. They are the hope of us all. In this blog, Amber Wilks shares a beautiful and wonderfully heartfelt expression of this universal principle.  It is so true, yet so personal. It is extremely well written and emotionally compelling. I love it. It brought tears to my eyes — tears not just for Amber, but for the pain of all neglected children. I deeply respect everyone who finds the courage that brings them  through the many painful ordeals and the many times of despair when giving up seems the only choice. Amber kept kept going through these times and she is making a diference. So are all survivors.”  ~ Terence T. Gorski

I have seen so many children, tossed aside, emotionally and physically neglected. The listless wandering in their eyes, bodies balanced precariously on unstable ground, hearts lost in a cold vacant world, just looking for warmth and acceptance. The gift would be small and unassuming in size, yet grand and everlasting. As innocent as a passing glance, this gift would often be overlooked by bustling brokers of the dysfunctional factual calibrated societal players. An irreplaceable momentary slip through the cracks of the degradation, dust, and dishevelment these glorious little miracles are growing-up in.

I too desired that gift as a child. I was regarded as a wee bit of gum on societies shoe; I searched many a day and night for this illustrious gift. I looked through window panes, peeked around darkened corners, and dug through the muck and the grime of the gutters. Days turned into weeks, weeks into months, than year upon year I searched until I reached the moment of absolute collapse and surrender.

Absolutely, irrevocably I was defeated. I was emotionally and physically battered and bruised. I lay down in my final act of letting go of all that I had been trying to fill myself with. Just then, as if looking up for the first time, I noticed the beauty that danced above my glance for so long. My heart began to warm and a stream of salty sweet tears drifted freely down my tattered cheek.

How could it be so simple, I wondered. Full of gratitude and amazement, overwhelmed with emotion, my body grew limp. I collapsed onto the ground, curling into the fetal position; I sobbed an uncontrollable expression of relief and contentment. My body was washed over with the feeling of complete acceptance. I found what I was looking for.

All children deserve to know that they are loved and cared for.

I believe that when a child is born they represent unlimited potential; that only they hold the keys to their futures and it is our job to guide them, for they hold the key to all of our futures. When I look into a child’s eyes, I see everything that they can accomplish. How they can turn all of the pain and suffering into something beautiful. Their experiences, light or dark, hold the answers to the universe’s mysteries.

I want to give all children an ever burning light of wonder, discovery, and expression. This, you can see burning in the young and the old, regardless of station in life; if you have it, it will always shine through. Some call it a sparkle, others a glimmer, and yet still more describe it as radiating. Whatever you want to call it, whenever a child looks to you, I wish you my gift – the ability to see the radiance shining through even the most horrible of circumstances.

Amber can be contacted at: Amber.wilks.7467@mail.linnbenton.edu


Diagnosing Codependence – A Practical Guide

December 8, 2013

Terence T. Gorski
November 01, 1992

imagesIn recent years, the exact meaning of the term codependence has become confused. This confusion is interfering with efficient diagnosis, appropriate treatment recommendations, and the funding of treatment. It is also creating confusion about the relationship between codependence and chemical dependence, and the relationship between codependence and other mental disorders.

In order to accurately define the term codependence — and try to clear up the confusion — let’s begin with a brief review of the history of the term and then describe the various meanings it has developed in current usage.

Historical Perspective

Shortly after the founding of Alcoholics Anonymous (AA) in 1935, it was recognized that adults who lived in committed relationships with alcoholics were damaged by those relationships. This damage was originally referred to as co-alcoholism. In the early 1940’s, AA Family Group Meetings, which later became Al-Anon, were organized to meet the needs of co-alcoholics (Al-Anon, 1979). In the late 1960’s and early 1970’s, treatment centers began to develop programs for families of alcoholics. At first, these programs were directed toward enlisting the support of family members in keeping alcoholic patients sober (NIAAA 1981, NIAAA 1987). The focus of these programs gradually shifted to meeting the needs of the co-alcoholics themselves. Co-alcoholism began to emerge as a separate diagnostic category.

Awareness began to grow that children raised by alcoholic parents suffered more severe and long-lasting damage than adults who were raised in non-alcoholic homes and later married alcoholics. A distinction was made between co-alcoholics (adults from non-alcoholic families who later married alcoholics) and para-alcoholics (children who were raised by alcoholic parents). The specific damage to children was discussed under the term Children of Alcoholics. Since this damage persisted into adulthood, the term Adult Children of Alcoholics (ACOA) came into widespread use. A Twelve-Step Support Group named Adult Children of Alcoholics was developed in the early 1980’s and grew rapidly.

In the late 1970’s, the term chemical dependence came into widespread use and the term alcoholism was conceptualized as a subtype of chemical dependence. As a result, the term co-alcoholic was generalized as the term codependent. As the ACOA movement grew, the term codependent was used to describe both adults who were damaged by marrying chemically dependent partners and children who were damaged by chemically dependent parents.

As more clinical observations were made of codependents (adults and children), it became apparent that people who were damaged by living in committed relationships with chemical addicts did not differ significantly from people damaged by living in committed relationships with other dysfunctional people. The term codependent was therefore expanded again to account for all people who have been damaged by living in a relationship with a dysfunctional person, regardless of the cause of the dysfunction. The term Adult Children from Dysfunctional Families (ACDF) began to be utilized.

As efforts were made to describe the personality characteristics of these now broadly defined codependents, it was discovered that some, but not all, had a personality that was organized around low self-esteem, obsessive involvement with others in order to raise self-esteem, and extreme caretaking behavior that resulted in lack of self-care. This observation caused many people to begin using the term codependence to describe that particular personality style.

Current Usage

As a result of this steady broadening of the concept, the current usage of the term codependence involves four distinctly different definitions:

1.         Codependence is a cluster of symptoms or maladaptive behavior changes that occur in adults who live in a committed relationship with a chemically dependent person. (Al-Anon.)

2.         Codependence is a cluster of symptoms or maladaptive behavior changes that occur in children who are raised by chemically dependent parents. (ACOA.)

3.         Codependence is a cluster of symptoms or maladaptive behavior changes associated with living in a committed relationship with either a chemically dependent person or a chronically dysfunctional person either as children or adults. (ACDF.)

4.         Codependence is a specific pattern of personality traits that are characterized by loss of self-identity, over-involvement with others as a means of establishing self-identity, and excessive caretaking behavior that results in a lack of self-care. (Everyone else.)

The Simple Solution

The easiest solution to the problem of uniform language would be to acknowledge all four general definitions and draft specific language to accurately describe their meanings. This solution, however, would not end the confusion over what is meant by the term codependence. Rather, it would simply force people using that term to specify the exact meaning that they mean to convey.

A Better Solution

A better solution would be to create a special nomenclature that readily differentiates between these four different meanings. The following nomenclature could be used.

Codependent: A general term describing a cluster of symptoms or maladaptive behavior changes associated with living in a committed relationship with either a chemically dependent person or a chronically dysfunctional person either as children or adults.

This term could be further specified using the following terms:

Codependent Adjustment Reaction: A subtype of codependency characterized by the spontaneous remission of codependent symptoms when the person is no longer in the committed relationship with the chemically dependent or chronically dysfunctional person.

Codependent Disorder: A subtype of codependency characterized by the continuation of codependent symptoms even when the person is no longer in a committed relationship with the chemically dependent or chronically dysfunctional person.

Child Onset Codependence: A subtype of codependency (either codependent adjustment reaction or codependent disorder) that is caused by being raised in an addictive or dysfunctional family of origin.

Adult Onset Codependency: A subtype of codependency (either codependent adjustment reaction or codependent disorder) that is caused by being involved in a committed relationship as an adult with an addicted or dysfunctional person.

Severity Scale

Codependent symptoms can vary in intensity from mild to severe. The following severity scale can be used:

1.         Mild codependent symptoms produce subjective distress, but create no social or occupational impairment.

2.         Moderate codependent symptoms produce subjective distress and create minimal social and occupational impairment.

3.         Severe codependent symptoms produce subjective distress and create substantial social or occupational impairment.

The Caretaking Personality Style

This term could be used to describe a specific pattern of personality traits that is characterized by loss of self-identity, over-involvement with others as a means of establishing self-identity, and excessive caretaking behavior that results in a lack of self-care. Both codependents and non-codependents can exhibit a caretaking personality. This can be uncategorized as:

1.         Caretaking Personality Traits:  A form of the caretaking personality that creates subjective distress but is not sufficient to cause social or occupational impairment.

2.         Caretaking Personality Disorder: A form of caretaking personality that is severe enough to cause social and occupational impairment.

The Relationship of Chemical Dependence and Codependence

Approximately 60% of all chemically dependent patients entering treatment for the first time (Hoffman and Harrison, 1986) and 90% of all chronically relapse-prone patients were raised in alcoholic family systems and would be appropriately described as having a multiple diagnosis of chemical dependence and child onset codependence. This high rate of multiple diagnoses has led to confusion about the relationship between codependence and chemical dependence.

If we use the definition of codependence as symptoms resulting from damage caused by living in a committed relationship with a chemically dependent or dysfunctional person, there would be two possible relationships between codependence and chemical dependence.

1.         Codependence could cause chemical dependence, or

2.         Codependence and chemical dependence could be co-existing disorders that have no causative relationship, but do interact dynamically with each other.

There is substantial evidence that codependence (i.e. being raised in a dysfunctional family) does not cause chemical dependence, but can cause serious complications that can interfere with recovery and increase the risk of relapse (Gorski, 1989).

Therefore, the recommended position on the relationship of codependency to chemical dependency is this: Codependency and chemical dependency are independent conditions that often co-exist. Being chemically dependent does not cause a person to develop codependence. Being codependent does not cause a person to develop chemical dependence. Many people suffer from codependence and chemical dependence at the same time. In any event, the presence of codependence can interfere with recovery from chemical dependence. By the same token, the presence of chemical dependence can interfere with recovery from codependence.

Appropriate treatment for a person suffering from chemical dependence and codependence would be:

1.         To bring the chemical dependence into remission first through a program of abstinence, detoxification, and the development of a recovery program;

2.         Treat severe codependency issues that increase the risk of relapse to chemical dependence;

3.         Treat the less severe codependence issues in late recovery after a stable sobriety program has been established.

Hopefully, the use of a system such as this will help guide us through the tangled jungle of terminology about codependence.

Read Gorski’s Blog On Family Involvement In Relapse Prevention

References:

Gorski, Terence T.. “Diagnosing codependence: a practical guide to understanding and treatment. (Special Section: Codependence)(includes related article).” Addiction & Recovery. 1992. Retrieved July 03, 2010 from accessmylibrary: http://www.accessmylibrary.com/article-1G1-13360084/diagnosing-codependence-practical-guide.html

Gorski, Terence T.. “Do Family of Origin Problems Cause Chemical Addiction?: Exploring the Relationship Between Chemical Dependency and Codependence” [Paperback], Herald House/Independence Press, Terence T. Gorski (Author) ON THE INTERNET: http://www.amazon.com/Family-Origin-Problems-Chemical-Addiction/dp/0830905448

Wikipedia, Codependency: ON THE INTERNET: http://en.wikipedia.org/wiki/Codependency


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