Cognitive Restructuring: Why It Works With Addiction

June 8, 2014

Addictive ThinkingBy Terence T. GorskiAuthor

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

COGNITIVE means information processing in the brain.

RESTRUCTURING means changing how information is processed by the brain.

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

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

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

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

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

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

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

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

Cognitive restructuring is a proven method for:

1. Stopping addictive thinking and challenging addictive beliefs;

2. Managing craving;

3. Stopping or redirecting addiction-seeking behaviors;

4. Avoiding or effectively managing high risk situations;

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

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

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

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

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

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

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

A small investment in this inexpensive workbook can:

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

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

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

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


Understanding Relapse and Relapse Prevention

February 2, 2014

By Terence T. Gorski, Author
August 18, 2006

imagesRelapse is more than just using alcohol or drugs. It is the progressive process of becoming so dysfunctional in recovery that self-medication with alcohol or drugs seems like a reasonable choice.

The relapse process is like knocking over a line of dominoes.  The first domino hits the second, which hits the third, and soon a progressive chain reaction has started.  The sequence of problems that lead from stable sobriety to relapse are similar to those dominoes, with two differences.  First, each domino in the line (i.e. each problem that brings us closer to substance use) gets a little bit bigger and heavier until the last domino, or problem, in the sequence is 10,000 pounds.  As this 10,000 pound domino begins to fall on us, it is too heavy for us to handle alone.  The second difference is that the problems circle around behind us.  So when the last domino or problem falls, it hits us from behind when we’re not looking.

So here we are, moving along in recovery.  We encounter one small problem.  No big deal!  Then we encounter another problem.  Soon a chain reaction begins.  The first problems are so small that we can easily convince ourselves they’re no big deal.  We look the other way and start doing other things.  All of a sudden a huge problem falls on us and causes serious pain and injury.  We need to make the pain go away and we reach for old reliable – the magical substances that always helped us with our pain in the past.  We’ve now started drinking and drugging.

The answer to avoiding relapse is to learn how not to tip over the first domino, and take care of the little problems in life.  Another part of the answer is to develop an emergency plan for stopping the chain reaction quickly, before the dominoes start getting so big and heavy that they become unmanageable.

The Relapse Process

The progression of problems that lead to relapse is called the relapse process.  Each individual problem in the sequence is called a relapse warning sign.  The entire sequence of problems is called a relapse warning sign list.  The situations that we put ourselves in that cause or complicate the problems are called high risk situations.

It’s important to remember that we don’t start drinking and drugging because of the last problem in the sequence.  We start drinking and drugging because the entire sequence of problems got out of control.  Let’s look at this process:

Step 1: Getting Stuck In Recovery

Many of us decide that alcohol or drugs are a problem, stop using, and put together some kind of recovery plan to help us stay sober.  Initially we do fine, but then we hit a problem that we are unwilling or unable to deal with.  We stop dead in our tracks.  We are stuck in recovery and don’t know what to do.

Step 2: Denying That We’re Stuck

Instead of recognizing that we’re stuck and asking for help, we use denial to convince ourselves that everything is OK.  Denial makes it seem like the problem is gone, but it really isn’t.  It just goes under ground where we can’t see it.  We keep investing time and energy in denying it which results in a buildup of pain and stress.

Step 3: Using Other Compulsions

To cope with the pain and stress, we begin to use other compulsive behaviors. We may begin overworking, over-eating, dieting, or over-exercising. We can get involved in addictive relationships and distract ourselves with sex and romance.  These behaviors make us feel good in the short run by distracting us from our problems.  But they do nothing to solve the problem.  We feel good now, but we hurt later.  This is a hallmark of all addictive behaviors.

Step 4: Experiencing A Trigger Event

Then something happens.  It’s usually not a big thing.  It’s something we could normally handle without getting upset.  But this time something snaps inside.  One person described it this way: “It feels like a trigger fires off in my gut and I go out of control.”

Step 5: Becoming Dysfunctional On The Inside

When the trigger goes off, our stress increases, and our emotions take control of our minds.  To stay sober we have to keep intellect over emotion.  We have to remember who we are (an addicted person), what we can’t do (use alcohol or drugs), and what we must do (stay focused upon working a recovery program).  When emotion gets control of the intellect we abandon everything we know, and start trying to feel good at all costs.

Relapse almost always grows from the inside out.  The trigger event makes our pain so severe that we can’t function normally.  We have difficulty thinking clearly.  We swing between emotional overreaction and emotional numbness.  We can’t remember things.  It’s impossible to sleep restfully and we get clumsy and start having accidents.

Step 6: Becoming Dysfunctional On The Outside:

At first this internal dysfunction comes and goes.  It’s annoying, but we learn how to ignore it.  On some level, we know something is wrong, but we keep it a secret.  Eventually we get so bad that the problems on the inside create problems on the outside.  We start making mistakes at work, creating problems with our friends, families, and coworkers, start neglecting our recovery programs.  Things just keep getting worse.

Step 7: Losing Control

We try to handle each problem as it comes along but miss the growing pattern of problems.  We never really solve anything.  It’s just band-aid after band-aid.   Then we look the other way and try to forget about the problems by getting involved in compulsive activities that will somehow magically fix us.

This approach works for a while, but eventually things start getting out of control. As soon as we solve one problem, two new ones pop up.  Life becomes one problem after another in an apparently endless sequence of crisis.  One person put it like this: “I feel like I’m standing chest deep in a swimming pool trying to hold three beach balls underwater at once.  I get the first one down, then the second, but as I reach for the third, the first one pops back up again.”

We finally recognize that we’re out of control.  We get scared and angry.  “I’m sober!  I’m not drinking!  I’m working a program!  Yet I’m out of control.  If this is what sobriety is like – who needs it?”

Step 8: Using Addictive Thinking

Now we return to addictive thinking.  We begin thinking along these lines:  “Sobriety is bad for me, look at how miserable I am.  Sober people don’t understand me.  Look at how critical they are.  Maybe things would get better if I could talk to some of my old friends.  I don’t plan to drink or use drugs, I just want to get away from things for a while and have a little fun.  People who supported my drinking and drugging were my friends.  They knew how to have a good time.  These new people who want me to stay sober are my enemies.  Maybe I was never addicted in the first place.  Maybe my problems were caused by something else.  I just need to get away from it all for a while!  Then I’ll be able to figure it all out.”

Step 9:  Going Back To Addictive People, Places, And Things

Now we start going back to addictive people (our old friends), addictive places (our old hangouts), and addictive things (mind polluting compulsive activities).  We convince ourselves that we’re not going to drink or use drugs.  We just want to relax.

A client in one of my groups said he wanted to go to a bar so he could listen to music and relax while drinking soft drinks.  An old-timer in the group asked:  “If you told me you were going to a whore house to say prayers, do you think I’d believe you?”

Step 10: Using Addictive Substances

Eventually things get so bad that we come to believe that we only have three choices – collapse, suicide, or self-medication.  We can collapse physically or emotionally from the stress of all our problems.  We can end it all by committing suicide.  Or we can medicate the pain with alcohol or drugs.  If these were your only three choices, which one sounds like the best?

At this stage the stress and pain is so bad that it seems reasonable to use alcohol or drugs as a medicine to make the pain go away.  The 10,000 pound domino just hit.  We’re dazed, and in tremendous pain.  So we reach out for something, anything that will kill the pain.  We start using alcohol and drugs in the misguided hope it will make our pain go away.

Step 11: Losing Control Over Use

Once addicted people start using alcohol or drugs, they tend to follow one of two paths.  Some have a short-term and low consequence relapse.  They recognize that they are in serious trouble, see that they are losing control, and manage to reach out for help and get back into recovery.  Others start to use alcohol or drugs and feel such extreme shame and guilt that they refuse to seek help.  They eventually develop progressive health and life problems and either get back into recovery, commit suicide, or die from medical complications, accidents, or drug-related violence.

Other Outcomes Of The Relapse Process

Some relapse prone people don’t drink.  They may say “I’d rather be dead than drunk” and they either attempt or commit suicide.  Others just hang in there until they have a stress collapse, develop a stress related illness, or have a nervous breakdown.  Still others use half measures to temporarily pull themselves together for a little while only to have the problems come back later.  This is called partial recovery and many people stay in it for years.  They never get really well, but they never get drunk either.

What I have just described is called the relapse process and it’s not uncommon.  Most recovering people periodically experience some of these warning signs.  About half can stop the process BEFORE they start using substances or collapse from stress.  The other half revert to using alcohol or other drugs, collapse from stress related illness, or kill themselves.

It’s not a pretty picture.  No wonder we don’t want to think or talk about relapse.  It’s depressing.  The problem is that refusing to think or talk about it doesn’t stop it from happening.  As a matter of fact ignoring the early warning signs makes us more likely to relapse.

But there is hope.  There is a method called Relapse Prevention that can teach us to recognize early warning signs of relapse and stop them before we use alcohol and drugs, or collapse.

Books and Takes On Relapse Prevention|

The New Opiate Addict

January 11, 2014

By Terence T. Gorski, Author
January 11, 2014


Men Get Addicted

A Profile of the New Opiate Addict

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


Siobhan A. Morse, Researcher

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

Detailed Information On The New Opiate Addict

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

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

– 11.8% reported heroin use,

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


Women Get Addicted

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

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

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

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

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

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

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

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

Opiate Use Fact Sheet

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

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

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

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

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

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

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

Read the entire study on the internet.




Read Straight Talk About Addiction
By Terence T. Gorski

Dark Thoughts: Personal and Collective

January 8, 2014
1508552_705489946150179_333021707_nBy Terence T. Gorski, Author
January 8, 2014

Dark thoughts can envelop our soul. We create some of these thoughts from personal experience, but not all of them.  Real but hidden threats cause some of these thoughts. Historical memory of devastating wars, poverty, and disease are the source of others. Many dark thoughts come from the collective unconscious of the group mind reflected in the deep rumblings of  the core violence of human culture.

There are bigger currents of humanity that move through our minds – a collective current that touches us all but is acknowledged by few. Our troubled violent history and current problems disturb us to the core of our being. It is easier to deny, to self-medicate, to distract with destructive pursuits. To look away is tempting. Denial, however, does not work very well in changing reality.

Human civilization is dark and violent. Human beings have a long history of collective and personal violence. War and violent crime have plagued humanity since before the beginning of written history.  The first recorded war occurred over 5,000 years ago and human beings have been systematically slaughtering each other with the best available technology ever since. War is the primary driver of technology and economic development.

Violence may have created and certainly sustains human culture. Read the Bible or the Koran and take note of the wide-spread murders, wars, plundering of cities, the women raped and murdered, and children put to the sword. Much of this slaughter was done in the name of God. It was also done to get new lands and steal the wealth of others. It is too often rationalized as the will of god.

The violence that permeates culture creates chronic pain called ANGST – the universal pain of the human condition. Living with the conscious knowledge that we will die causes us fear. To know that we need to love and the violence causes more violence causes shame and guilt when we live a world where life must feed upon life in order to survive. Addiction may well be a universal cross-cultural mechanism for managing this primal fear. There seems to be a strong relationship between fear of violence and both addiction and mental health problems. There is strong evidence that primitive religion emerged as a result of ritual practices to stop collective mob violence in primitive communities.

As long as we deny the violence all around us and pretend that it doesn’t exist, we ware part of the problem. We silently enable the violence and refuse to see what we are doing. The dark thoughts that we push deep into our mind, however, haunt us and often emerge at unexpected times. We are all guilty of perpetrated or enabling violence.

While hanging on the cross Jesus said: “Father, forgive them for they know not what they do.” This statement tells us why we are all culpable for the violence that surrounds us. If we don’t continue to improve our violence control mechanisms based on human empathy, individual societies and the world can lapse again into world war and domestic riots.

Tremendous resources are invested in national and international violence control mechanisms. War is expensive. So is crime.  Many of us prefer to deny this fact. It is easier to pretend that civilization is based upon a foundation of peace and love. It’s not! History has taught us that denial of violence does not work. Denial results in more violence. The social processing of violence, in a peaceful way, is necessary to establish any solid foundation for future peace.

It is hard to accept the truth and then stand for something better – a higher truth that we are also a part if something better. The problem is that power structure of the world has a solid foundation and a need for perpetual violence. To develop a peacetime economy that is not preparation for war is a goal that has yet to be achieved.



The GORSKI-CENAPS Model: A Comprehensive Overview

December 31, 2013

Recovery and Relapse Prevention
A Comprehensive Overview of a

Research-Based System that Works

By Terence T. Gorski
The CENAPS® Corporation

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

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

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

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

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

Table of Contents

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

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

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

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

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

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

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

The GORSKI-CENAPS® Corporation … 35

References On The GORSKI-CENAPS® Model … 36

Bibliography On The Recovery Process … 40

Part 1: Overview of the GORSKI-CENAPS® Model

General Description (Revised December 31, 2013)

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

Research Basis

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

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

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

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

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

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

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

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

Theoretical Models

There are three primary theoretical models upon which the GORSKI-CENAPS model is constructed.  These are the Biopsychosocial Model of Substance Use Disorders, the Development Model of Recovery, and the Relapse Prevention Model.  Each of these components is built upon a solid foundation of research studies.

The Biopsychosocial Model:  The Biopsychosocial Model of Addiction is based upon an integration of four science-based models of addiction: Neuropsychological Predisposition Model, Neuropsychological Response Model, the Social Learning Model, and The Cognitive Therapy Model of Substance Abuse.  The components of these models have been translated into simple language and carefully integrated for consistency.  The basic research-based components of these models will be briefly explained so their application with the GORSKI-CENAPS Model can be easily recognized.

1.  Neuropsychological Predisposition Model[2]:  The Neuropsychological Predisposition Model describes the preexisting brain and central nervous system problems that increase the risk of becoming addicted.  These predisposing neuropsychological risk factors may be related to genetically inherited traits, brain dysfunction caused by improper prenatal care, the effects of prenatal alcohol or drug use, physical neglect (the absence of touching, rocking, and responsive loving human interaction) or abuse in early infancy, severe psychological trauma experienced at different points in childhood and adolescent development.

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

These predisposing neuropsychological problems are:  (1) the tendency to have severe mood swings, (2) difficulty in concentrating, (3) difficulty persisting in tasks through completion, (4) impulse control problems, (5) the tendency to be hyperactive and irritable, and (6) cognitive impairments that interfere with self-awareness, awareness of the immediate environment, abstract reasoning, problem solving, learning from past experiences, and the logical consequences of current behavior to anticipate and avoid future problems.

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

2.  Neuropsychological Response Model of Addiction[4]The Neuropsychological Response Model describes the primary reactions of the brain and nervous system to the ingestion of alcohol and drugs that motivate people to keep using in progressively greater amounts and to have difficulty stopping even after serious problems develop.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Developmental Model of Recovery (DMR)

The Developmental Model of Recovery (DMR) was initially developed from the observations of client’s recovery over the course of two years of outpatient substance abuse treatment.  This model was first published as the Chapter of a recovery education book in 1982[10], as a training manual in 1985[11], and by Hazelden in 1989[12].

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

6.         The Relapse Prevention Model

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

Target Population

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

1.  Have average or above average conceptual skills

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

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

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

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

Adaptation To Special Populations

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

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

2.  Adults

3.  Adolescents

4.  Families

5.   Addicted patients with pain disorders

6.   Relapse-prone African Americans

7.   Relapse-prone Native Americans

8.   Addicted patients with coexisting eating disorders

9.   Revolving door, indigent detox patients

10. Physically and sexually abused men and women

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

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

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

Levels of Clinical Application

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Counselor Characteristics

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

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

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

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

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

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

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

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

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

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

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

The primary focus of all sessions is to guide the patient in the completion of structured exercises contained in a patient workbook.  Workbooks are available for Denial Management, Relapse Prevention Counseling: Practical Exercises for Managing High-Risk Situations, Relapse Prevention Therapy: Managing Core Personality and Lifestyle Issues, Addiction-Free Pain Management, Recovery and Relapse Prevention for Food Addiction, and others.  A process has been developed for custom designing treatment manuals (i.e. client workbooks) that address specific recurrent issues within treatment programs.

All applications of the GORSKI-CENAPS® Model rely on the use of core clinical skills directed at teaching clients specific recovery skills.  The basic recovery skills that are adapted to each level of a patient’s recovery are:

1.   Introspection Skills:  The ability to identify self-talk, feelings and emotions, and urges to act.

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

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

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

5.   Behavioral Skills:  The two core behavioral skills are impulse control and self motivation.  Impulse control is the ability to recognize cravings and self-destructive urges and to stop acting out on those cravings or urges.  Self-motivation is the ability to force yourself to engage in healthy and productive behavior even when you don’t want to.

6.  Social Skills:  A relationship building model based upon levels of relationship is used to guide clients in slowly rebuilding their social network.  The core social skills involved in the social rebuilding process are: the ability to engage in productive communication using an active listening model, the ability to set and enforce appropriate boundaries and limits in social situations, the ability to stop using controlling and manipulative behaviors, and the ability to engage in negotiation and conflict resolution.

7.  Problem & Warning Sign identification:  The ability to identify and develop a personalized list of the unique personal problems that lead the person back to alcohol and drug use (called relapse warning signs) and problem or warning sign management strategies which consist of concrete situational and behavioral coping strategies for managing the warning signs without returning to chemical use.

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

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

Compatibility With Other Models and Standards

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

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

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

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

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

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

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

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

Approaches Most Similar

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

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

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

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

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

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

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

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

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

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

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

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

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

Compatibility With Standards

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

Setting of Treatment

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

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

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

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

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

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

Duration of Treatment

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

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

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

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

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

The Conceptual Models of the GORSKI-CENAPS® System

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

Biopsychosocial Model of Addiction (Revised December 31, 2012)

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

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

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

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

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

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

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

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

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

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

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

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

Developmental Model of Recovery

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

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

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

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

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

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

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

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

Relapse Prevention Model

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

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

Cognitive, Affective, Behavioral, Social (CABS) Therapy

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

The Primary Psychological Systems:  The primary psychological systems are:

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

(2)  Cognitive System (regulates thinking),

(3)  Affective system (regulates feeling and emotion)

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

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

The Primary Social Systems:  The primary social domains are:

(1) Work

(2) Friendship

(3) Intimate /Family

Preferred Modes of Psychosocial Functioning

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

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

Standard Treatment Modalities

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

Agent Of Change:

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

Treatment Planning Components

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

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

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

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

(2) Write a prioritized list

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

(4)  Create a long-term recovery vision

(5) Referral to the next appropriate type of treatment

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

The Goals of Denial Management Counseling (DMC) are:

(1) Stop denial and resistance

(2) Referring for Primary Recovery Counseling (PRC)

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

The Goals Of Primary Recovery Counseling (PRC)

(1) Teach foundational recovery skills

(2) Refer for Relapse Prevention Therapy (RPT)

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

The Goals of Relapse Prevention Counseling (RPC)

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

(2)       Referral to the next appropriate type of treatment

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

The Goals of Relapse Prevention Therapy (RPT)

(1)       Identify and manage core personality and lifestyle issues

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

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

Helping Characteristics

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

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

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

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

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

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

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

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

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

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

Interviewing Skills

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

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

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

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

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

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

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

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

Treatment Delivery Systems

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

7. Share personal experiences with similar problems when appropriate.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Strategies For Dealing With Common Clinical Problems

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The GORSKI-CENAPS® Corporation

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

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

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

References On The GORSKI-CENAPS® Model

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

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

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

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

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

Daley, Dennis C. and Marlatt, G. Alan, Relapse Prevention; IN EDS: Lowinson, Joyce H., Ruiz, Pedro, Millman, Robert B., and Langrod, John G., Substance Abuse:  A Comprehensive Textbook, Williams & Wilkins, Baltimore 1997

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Gorski, Terence T., Passages through Recovery: An Action Plan for Preventing Relapse, Hazelden, 1989

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

on Alcoholism, Addiction Research Foundation, Toronto, Canada 1988

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

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

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

Bibliography On The Recovery Process

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

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

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

Gorski, Terence T., Passages through Recovery: An Action Plan for Preventing Relapse, Hazelden, 1989

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

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

Miller, Merlene, Gorski, Terence T., and Miller, David K., Learning to Live Again: A Guide to Recovery from Alcoholism. Independence, Missouri, Independence Press, 1982, pp. 123-128.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[10] Miller, Merlene, Gorski, Terence T., and Miller, David K., Learning to Live Again: A Guide to Recovery from Alcoholism. Independence, Missouri, Independence Press, 1982, pp. 123-128

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

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

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

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

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

[16] Daley, Dennis C. and Marlatt, G. Alan, Relapse Prevention; IN EDS: Lowinson, Joyce H., Ruiz, Pedro, Millman, Robert B., and Langrod, John G., Substance Abuse: A Comprehensive Textbook, Williams & Wilkins, Baltimore 1997

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

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

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

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

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

Craving & Relapse

December 30, 2013

Craving Hurts

by Terence T. Gorski, Author
December 31, 2013


Addicts often relapse because they are overwhelmed by a powerful sense of craving.  The physiological craving is powerful and, as a result, the issue of craving needs to become a primary concern in preventing relapse—especially during the first 90 to 120 days of recovery.  To responsibly focus upon the issue of craving requires a comprehensive bio-psychosocial model that will help us understand the craving process.

In 1990, I developed a three-stage model for managing craving.  The three stages of craving are:

Stage 1: Set-up behaviors: Ways of thinking, managing feelings, and behaving that increase the risk of having a relapse

Stage 2: Trigger Events:  Events that activate the physiological brain responses associated with craving.

Stage 3: The Craving Cycle:  A series of self-reinforcing thoughts and behaviors that continue to activate and intensify the craving response.

It is important to note that craving is the last step of a three-stage process.  It is self-defeating to focus on the end result, craving, without focusing on the factors that cause the craving.

Recovering people unconsciously set themselves to experience cravings.  The set-up behaviors lower their resistance to craving.  When their resistance is down, they’re vulnerable to trigger events that cause the actual feeling of craving to start.  Once they feel the urge to use, they start using habitual behaviors that amplify or make the craving worse.  This is the craving cycle.  Fortunately, there are prevention and intervention techniques available in this high time of need.

Stage One Set-Up Behaviors

Set-up behaviors are a combination of physical, psychological, and social factors that lower resistance to craving.

Physical Set-ups For Craving

There are five common physical set ups for craving.

1. Brain Dysfunction From Drug Use:  Mind altering drugs damage the brain and leaves recovering addicts physically set up to experience powerful cravings.  The result of this physical predisposition to experience craving is if recovering addicts don’t do special things to avoid craving, they will experience craving.

2. Poor Diet: Recovering addicts are often nutritional disaster areas because they live on junk food and don’t know what a healthy meal is.  Many have coexisting eating disorders that lead to binges on junk food and/or starving for days at a time to deal with the result of weight gain.

3. Excessive Use Of Caffeine And Nicotine: Both caffeine and nicotine of these are low-grade stimulant drugs and increase the likelihood of having a craving.

4. Lack Of Exercise: Aerobic exercise reduces the intensity of craving.  Regular aerobic exercise is a protective factor against craving, especially in the first six to nine months of recovery.  Not doing aerobic exercise on a regular basis sets the stage for craving.

5. Poor Stress Management: When recovering people don’t manage stress appropriately in recovery, they increase their risk of having craving by becoming stress sensitive.  Regular stress management activities such as meditation, relaxation exercises, taking regular breaks and rest periods are all protective factors against craving.

Psychological Set-Ups For Craving

There are five major psychological ways that recovering addicts set themselves up to experience craving.

1. Euphoric Recall: Euphoric recall is a way in which addicts “romance the high” by remembering and exaggerating the pleasurable experiences of past use, while blocking out painful and unpleasant aspects of the memory.

2. Awfulizing Abstinence: When addicts “awfulize” abstinence, they notice all of the negatives and exaggerate them while blocking out all of the positive aspects of recovery.  This leads the recovering addict to feel deprived in recovery and to believe that being sober is not nearly as good as using the drug.

3. Magical Thinking About Use: Magical thinking about use is the belief that using will solve all of their problems.  This magical thinking is brought about by the euphoric recall (“Remember how good it was!”), and the “awfulizing” of sobriety (“Look at how awful it is that I can’t use it.”).

4. Empowering The Compulsion: They exaggerate the power of the compulsion by telling themselves that they can’t stand not having the drug and telling themselves that there is no way to resist the craving.

5.  Denial and Evasion: The final psychological set-up is denial and evasion. Addiction is a disease of denial.  This denial does not go away simply because they are not using the drug.  Many addicts deny their need for a recovery program to reduce the likelihood of craving.  They also deny that they are setting themselves up to have craving for the drug.   Because this denial is an unconscious process, many addicts believe they are doing the best they can in recovery when, in fact, they are not.

Social Set-Ups For Craving

There are three major social ways that addicts set themselves up to experience craving.

1. Lack Of Communication:  Addicts stop talking about their experiences in recovery and, as a result, they get into trouble.  They replace rigorous honesty with superficial communication.  This isolates them and prevents them from doing a sanity check on their recovery experiences.

2. Social Conflict: Out of isolation and a refusal to communicate comes a tendency to get into arguments and disagreements with other people.  This social conflict prompts the recovering addict to avoid sober social situations and isolate themselves from others, spending more time alone.

3. Socializing With Other Drug-Using Friends:  Out of loneliness and desire to be with people who understand them, many recovering addicts decide to associate with people who they used to drink and drug with.  This puts them in the proximity of the drug and sets them up to have a craving.

Stage 2: Trigger Events For Craving

There are four primary types of triggers that activate immediate craving.  These triggers include thoughts, feelings, behaviors, and situations that activate craving. Once these triggers are activated, a powerful craving to use emerges.

1. Thought Triggers:  Thought triggers arise out of addictive thinking or an addictive mind-set that creates thoughts about the role that alcohol or other drugs play in a person’s life.

2. Feeling Triggers:  Feeling triggers come from sensory cues – seeing, hearing, touching, tasting, or smelling something that reminds them of drug of choice.  It also results from experiencing feelings or emotions that were normally medicated by use.

3. Behavioral Triggers: The behavioral triggers deal with drug-seeking behaviors and rituals that activate a craving.

4. Situational Triggers:  Situational triggers include any stressful relationships or situations that used to be engaged in on a regular basis while using.

Stage 3: The Craving Cycle

The third and final stage of craving is the actual craving cycle.  This cycle is marked by obsession, compulsion, physical craving, and drug-seeking behavior. This cycle can be prevented and there are helpful intervention techniques when it arises.

1. Obsession:  When the obsession is activated, the person has out-of-control thinking about using.  Intrusive thoughts invade their mind and they can’t turn them off.  The obsession quickly turns into a compulsion.

2. Compulsion:  When compulsion is activated the person begins experiencing an overwhelming urge to use the drug even though they consciously know that it is dangerous to do so.

3. Craving:  The obsession and compulsion merge into full-blown physical craving.  Physical craving is marked by a strong desire to use the drug, rapid heart beat, shortness of breath, perspiration, and at times the actual sense of tasting, smelling, or feeling the drug of choice.  Physical craving is very powerful.

4. Drug Seeking Behavior:  In an effort to manage the obsession, compulsion, and physical craving, many addicts activate drug-seeking, ritual behavior.  They begin to cruse old neighborhoods, talk with old drug using friends, and go to bars and other places where a drug of choice is available.  This exposes the person to more triggers–which intensify the craving cycle.  Eventually, the person becomes overwhelmed with a compulsion that they cannot control and they return to drug use.

Preventing Craving

Craving can be prevented by following a number of simple guidelines.

1. Recovery Program: Develop a structured recovery program that puts you in continuous daily contact with other recovering people.

2. Know Your Triggers: Identify the things that activate the craving and learn how to cope with those triggers.

3. Know & Avoid And Set-up Behaviors:  Know your set-up behaviors and learn how to avoid or cope with those set-up behaviors.  If you don’t set yourself up for craving, when you do have a craving they will be less severe and last for a shorter length of time.

4. Dismantle Euphoric Recall:  Carefully examine past pleasant memories about using and search for the hidden negatives in the experience.  Most people find that they had no purely positive experiences while using their drug of choice.  There were always hidden negatives.

5. Stop Magical Thinking:  It is also important to stop magical thinking about future use and to stop “awfulizing” your current sobriety.  This will allow you to deal with the physical set-ups and let you know what to do to stop a craving.

Intervening On An Episode Of Craving

Since craving is a normal and natural symptom of addiction that follows the addict into recovery, it is important for addicts to learn how to deal with craving in recovery.  This is done by learning and practicing a number of steps.

1. Recognize Craving:  Addicts must learn how to recognize a craving while it is happening. Many addicts fail to identify mild cravings as problematic and wait until they are in a full-blown, severe craving before taking action.

2. Accept Craving As Normal:  Many people experience a craving, panic, and believe there is something wrong with their recovery or that they are condemned to return to their drug of choice.  This is not true.

3. Go Somewhere Else: The craving was probably activated by an environmental trigger, so get out of the setting you’re in and get into an environment that supports sobriety.

4. Talk It Through: If you talk it through, you don’t have to act it out.  Addicts need to talk about their cravings as soon as they occur to discharge the urge to use.

5. Aerobic Exercise:  This stimulates brain chemistry and reduces the physiology of craving.

6. Eat A Healthy Meal: Eat a healthy meals in order to nourish the brain.  Consume some lean fish or meat for protein and eat some whole wheat bread or baked, potatoes or brown rice for complex carbohydrates.  It also helps to take some vitamins and amino acids to help stabilize brain chemistry imbalances.

7. Meditation And Relaxation:  Cravings are worse when a person is under high stress.  The more a person can relax, the lower the intensity of the craving. See a related blog on Mindfulness Meditation:

8. Distraction:  divert attention from the craving by engaging in other activities that productively distract the person from their feelings.

9. Remember Cravings Are Time-limited: The ninth step is to remember that most craving is time limited to two or three hours.  If you can use the previous eight steps to get yourself fatigued enough to fall asleep, most people wake up and the craving is gone.

It is possible to understand drug craving and to learn how to manage craving without returning to use. A model that allows people to identify set-up behaviors, trigger events, and the cycle of craving itself, and intervening upon this process has proven effective in reducing relapse among addicts.


Gorski, Terence T., Addiction & Recovery Magazine, April 10, 1991

Gorski, Terence T., Managing Cocaine Craving, Hazelden, Center City, June 1990

About the Author

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

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






Mental Illness Hits 20% of the US Population

December 21, 2013

By Terence T. Gorski
December 21, 2013


Mental Illness Hurts!
Especially If You’re In Jail
When You Should Be In Treatment!

SAMHSA’s 2012 National Survey on Drug Use and Health brought out many new statistics that are not very encouraging.  I decided to share a recent SAMHSA Newsletter that reported the major findings.

– Nearly 20% of the population experienced a diagnosable mental illness in 2011. This is 43.7 million people. Less than half (43%) received any treatment.

– Adults who experienced mental illness in the past year were three times more likely to have met the criteria for a substance use disorder than those who had not experienced mental illness in the past year (19.2 percent versus 6.4 percent).

– Those who had serious mental illness in the past year were even more likely to have had substance dependence or abuse (27.3 percent).

– 9 million American adults (3.9 percent) had serious thoughts of suicide in the past year

– 2.7 million (1.1 percent) made suicide plans

-1.3 million (0.6 percent) attempted suicide

Our kids are not in very good shape either.

– In 2012 about 2.2 million youth aged 12 to 17 (9.1 %) experienced a major depressive episode.

– Young people suffering from depression were more than three times as likely to have a substance use disorder (16.0 percent) than their counterparts who had not experienced a major depressive episode (5.1 percent).

The White House has the answer!
Another website:  

alcohol-effects-economyI am surprised that this newsletter DID NOT MENTION:

(1) The rising rates of depression and suicide in our military troops both during active duty and after discharge. (People tend to get depressed after serving multiple combat shifts and having their retirement benefits cut.)

(2) That every year there is an increasing number of educated and licensed mental health professionals at work in the USA. The wide variety of name brands, degrees, and licenses is too mind boggling for me to describe, so I will leave that to Mental Heath America.

(3) In spite of the growing number of mental health professionals the rate of mental illness and substance use disorders is still on the rise.

Question: Is there something wrong with this picture. More professionals working on the problem – the more people who are suffering from mental illness and substance abuse. Could there be something hidden in plain view that is driving up the rates of substance abuse and mental illness?


Mental Illness On the Rise.

(4) The evidence that suggests mental health problems, substance use disorders, and other behavioral addictions such as gambling and sexual addiction all go up during economic hard times.  Hunger and homelessness is on the rise in this sluggish economy. The results of this prolonged economic turn-down is more severe than people think. Read the report for yourself.

(5) The rates of mental illness continue to rise in spite of record sales in psychiatric medications, especially antidepressants.

It has been a long-standing Federal and State Government policy to reduce costs by cutting mental health beds in long-term residential psychiatric hospitals. The government decided to return the severe and chronically mentally  ill to the community. As a result, in 2012 the USA has a shortage of psychiatric beds.
For every 20 public psychiatric beds that existed in the US in 1955, only one such bed existed in 2005.
The full story of the rise and fall of long-term psychiatric hospitals is clearly described in The Encyclopedia of New Zealand. The history closely parallels what was happening in the United States and world-wide.  When they can’t function in the community due to their mental illness, many end up in the worst possible place for a mentally ill person — prison.
According to The Human Rights Watch the prisons have become the primary psychiatric treatment facilities. The brutality to the mentally in prison is too horrible to imagine. Read the full report if your stomach is strong enough to see the truth.

“Prisons are woefully ill-equipped for their current role as the nation’s
primary mental health facilities.” said  Jamie Fellner, Director,
U.S. Program of Human Rights Watch.
There are serious consequences of cutting back on the treatment resources for the mentally ill over the past several decades:The Treatment Advocacy Center reports that because there are so few beds available, individuals with severe psychiatric disorders who need to be hospitalized are often unable to get admitted. Those who are admitted are often discharged prematurely and without a treatment plan. The consequences of the radical reduction in psychiatric hospital beds are evidenced in the following areas:

  • Homelessness.  A 2005 federal survey estimated that approximately 500,000 single men and women are homeless in the United States at any given time and multiple studies have reported that one-third have a serious mental illness. A study in Massachusetts found that 27 percent of patients discharged from a state psychiatric hospital became homeless within six months of discharge; in a similar study in Ohio, the figure was 36 percent.
  • Jails and Prisons as Psychiatric Hospitals.  Since the radical reduction in public psychiatric hospital beds there has been a massive increase in severely mentally ill persons in jails and prisons. Conservative estimates have placed the number at 7 to 10 percent of all inmates, but some studies have put the figure at 20 percent or higher. The three largest de facto psychiatric institutions in the United States are the Los Angeles County Jail, Chicago’s Cook County Jail, and New York’s Riker Island Jail.
images“On any given day, between 25-30 percent of the inmates at Cook County Jail suffer from mental illnesses. The majority of these inmates are in jail for nonviolent offenses closely associated with their mental health issues and would be far better served by treatment rather than incarceration.” ~ Thomas J. Dart, Cook County Sherrif
  • Hospital Emergency Room Overflow.  Emergency rooms are often used as waiting rooms for people in need of a psychiatric bed. This backs up the entire hospital system and compromises other medical care. In Arlington, Virginia, county officials had to call 31 hospitals before finding one that would accept a patient.
  • Violent Crime.  Studies have shown that between 5 to 10 percent of seriously mentally ill persons who are not receiving treatment will commit a violent act each year. Such individual are responsible for at least 5 percent of all homicides.
The full SAMHSA newsletter is below. I wouldn’t worry, however, The Affordable Care Act will fix all of this right up. Kathleen Sibelius, Health and Human Services Secretary who reports to the President has promised it will all be fixed. She said: “The Affordable Care Act and new parity protections are expanding mental and substance use disorder benefits for 62 million Americans. This historic expansion will help make treatment more affordable and accessible.”

How Bad Does It Have To Get
Before We Rise UP And Say ENOUGH!!!

SAMHSA News Release

Date: 12/19/2013 9:00 AM
Media Contact: SAMHSA Press Office
Telephone: 240-276-2130

43.7 Million Americans experienced mental illness in 2012

$31 Million Announced to Improve Mental Health Services for Young People
Nearly one in five American adults, or 43.7 million people, experienced a diagnosable mental illness in 2012 according to the Substance Abuse and Mental Health Services Administration (SAMHSA). These results are consistent with 2011 findings.
SAMHSA also reported that, consistent with 2011, less than half (41 percent) of these adults received any mental health services in the past year. Among those who had serious mental illness, 62.9 percent received treatment. Among adults with mental illness who reported an unmet need for treatment, the top three reasons given for not receiving help were that they could not afford the cost, thought they could handle the problem without treatment, or did not know where to go for services.
The findings also shed light on mental health issues among young people. According to the report, 2.2 million youth aged 12 to 17 (9.1 percent of this population) experienced a major depressive episode in 2012. These young people were more than three times as likely to have a substance use disorder (16.0 percent) than their counterparts who had not experienced a major depressive episode (5.1 percent).
“The President and Vice President have made clear that mental illness should no longer be treated by our society – or covered by insurance companies – differently from other illnesses,” said Health and Human Services Secretary Kathleen Sebelius. “The Affordable Care Act and new parity protections are expanding mental and substance use disorder benefits for 62 million Americans. This historic expansion will help make treatment more affordable and accessible.”
“People will only benefit from all the progress we’ve made if they aren’t afraid to get help,” said SAMHSA Administrator Pam Hyde. “That’s why President Obama called for a national conversation on mental health and proposed a budget initiative to support making it easier for young people, adults, and families struggling with mental health problems to seek help and support.” (
The Administration recently launched to help people find easy-to-understand information about basic signs of mental health problems, how to talk about mental health and mental illness, and how to locate help.
In addition, SAMHSA is announcing two grant funding opportunities to help improve mental health services for young people:
  • Planning Grants for Expansion of the Comprehensive Community Mental Health Services for Children and Their Families Program – this grant program will provide $8 million in funding to assist states, political subdivisions, tribes, or territories to develop a comprehensive strategic plan for improving, expanding, and sustaining services provided through a system of care approach for children and youth with serious emotional disturbances and their families.
  • Implementation Cooperative Agreements for Expansion of the Comprehensive Community Mental Health Services for Children and their Families Program – this grant program will provide $23 million in funding to enable states, political subdivisions, tribes, or territories to improve behavioral health outcomes for children and youth with serious emotional disturbances and their families.
The new findings from SAMHSA also found that 9 million American adults 18 and older (3.9 percent) had serious thoughts of suicide in the past year–2.7 million (1.1 percent) made suicide plans and 1.3 million (0.6 percent) attempted suicide.
Those in crisis or knowing someone they believe may be at immediate risk of attempting suicide can call the National Suicide Prevention Lifeline 1-800-273-TALK (8255) or go to The National Suicide Prevention Lifeline network, funded by SAMHSA, provides immediate free and confidential crisis round-the-clock counseling to anyone in need throughout the country, every day of the year.
According to SAMHSA, adults who experienced mental illness in the past year were three times more likely to have met the criteria for a substance use disorder than those who had not experienced mental illness in the past year (19.2 percent versus 6.4 percent). Those who had serious mental illness in the past year were even more likely to have had substance dependence or abuse (27.3 percent).
The new findings come from SAMHSA’s 2012 National Survey on Drug Use and Health. In the survey, mental illness among adults aged 18 or older is defined as having had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) in the past year based on criteria specified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.
In this survey, serious mental illness is defined as mental illness that resulted in serious functional impairment, which substantially interfered with or limited one or more major life activities. A major depressive episode is defined as a period of at least two weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had at least four of seven additional symptoms reflecting the criteria as described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.
The complete survey findings from this report are available on the SAMHSA Web site at:

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.


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