In The Treatment Of Substance Use Disorders
Terence T. Gorski
(© Copyright, Terence T. Gorski, 2003)
Gorski Is Available To Train
& Consult On Best Practice Principles
Gorski - CENAPS, 6147 Deltona Blvd, Spring
Hill, FL 34606, 352-596-8000
|This article describes the basic research-based
principles upon which the GORSKI-CENAPS Model of treatment is
based. The article is divided into two parts.
Part 1: The Nature of Substance Use
Disorders: Part one describes the best scientific understanding of the nature of
substance use disorders.
1-2. Progressive Symptoms of
Progressive Symptom Model
Biopsychosocial Progressive Symptom Model
1-5. Characteristics of Substance Use
Part 2: Principles Governing Effective
Treatment: Part two describes the best
scientific understanding of the principles that govern the effective
treatment of substance use disorders. A listing of the references
from which these principles were derived is listed at the end of the
Nature Of Substance Use Disorders
Substance use disorders are primary biopsychosocial
conditions that result from the use of mind altering substances by
people who have biopsychosocial (physical, psychological and social)
risk factors that positively reinforce continued use of mind altering
substances and negatively
There are three types of Substance Related Disorders: Substance
Abuse Disorders, Substance Dependence Disorders, and Substance-induced
Disorders. The Substance-induced Disorders can coexist with either
Substance Abuse or Substance Dependence Disorders. (American
Psychiatric Association, 1994)
1. Substance Abuse Disorders marked by serious psychosocial
problems related to alcohol and drug use that do not meet the criteria
of a Substance Dependence Disorder. Abuse Disorders may result from initial experimentation with
mind altering substances, involvement in a lifestyle or subculture where
alcohol and drug problems are a social norm, or as a consequence of
related personality or mental disorders.
Patterns of substance abuse may be self-limiting or they may
become chronic. The severity of problems associated with substance
abuse can vary in response to the seriousness of
stress and related life problems. In
some cases substance abuse will progress into substance dependence.
2. Substance Dependence Disorders marked by an abnormal
biological responses to the ingestion of mind altering substances that
results in progressive tolerance and withdrawal that causes a a pattern
of compulsive use of the substance to develop which impairs the ability
to control substance use and results in the development of substance
related life problems.
Substance-induced Disorders: There are number of reversible
disorders that can be caused by the frequent and heavy use of alcohol
and other drugs that common that commonly coexist with substance use
disorders. These substance related disorders may be associated
with either substance abuse disorders or substance dependence
disorders. If these Substance Induced Disorders are not identified
and stabilized they can interfere the successful treatment of before
both substance abuse and substance dependence disorders. The
Substance-induced Disorders are: Intoxication, withdrawal, and
Substance-induced Mental Disorders.
Intoxication: Intoxication is a reversible set of
substance-specific symptoms that are caused by the recent ingestion of
alcohol or other drugs. The symptoms consist of significantly
maladaptive behaviors caused by impairments in the ability to think
clearly, manage feelings and emotions, and self-regulate behavior.
Intoxication is often marked by severe impairments in judgment and
impulse control. The symptoms persist as long as the blood alcohol
or drug level is high enough to cause them. Different substances
can cause similar symptoms or interact synergistically to create
distortions of the symptoms commonly associated with each drug when used
separately. (American Psychiatric Association 1994 pp. 183 - 184)
Withdrawal: Withdrawal is a reversible set of substance-
specific symptoms that are caused by the cessation or reduction in heavy
and prolonged substance use. (American Psychiatric Association
1994 pp. 184 - 187; NIAAA 1989)
Substance-induced Mental Disorders: Substance-induced
Mental Disorders are symptoms caused by the long term effects of
frequent and heavy use of alcohol or other drugs. These effects
cause impairments to the brain & nervous system; impaired cognitive
& affective functioning; or problems with behavioral control and
regulation. The symptoms may be related to intoxication, acute
withdrawal, post acute withdrawal (PAW), or long-term brain dysfunction
caused by alcohol or drug use. PAW and long-term brain dysfunction
are described as Substance-induced Persisting Disorders in
DSM-IV. (American Psychiatric Association 1994 pp. 192 - 195)
The primary Substance-induced Mental Disorders are:
Substance-induced Delirium: Perceptual
problems that include: difficulty maintaining environmental
awareness; difficulty focusing and sustaining attention on a task or
object; difficulty shifting attention from one central focus to another;
difficulty maintaining orientation tom person, place, time and context;
and problems understanding and communicating ideas verbally and in
writing. The symptoms are caused by the effects of substance
use that extends beyond the period of intoxication and acute
withdrawal. There are two common types of Substance-induced
Delirium - Intoxication Delirium and Withdrawal Delirium. (American
Psychiatric Association 1994 pp. 127 - 129) If not properly
treated, mild to moderate symptoms of Substance- induced Withdrawal
Delirium may persist for as long a 60 to 180 days following the
cessation of substance use and become worse during periods of high
Substance-induced Persisting Dementia: Cognitive
impairments including: memory impairments involving the impaired ability
to recall previously learned information and/or learn and retain new
information (American Psychiatric Association 1994
pp. 152 - 155; NIAAA 1989b). The most common substance-induced
cognitive impairments are:
Disturbances In Executive
Functioning that make it difficult to plan, organize, sequence,
abstract central organizing principles, apply past experience to current
situations, and project logical consequences of current behavior into
(aphasia) that make it difficult to comprehend what is read and and
understand complex or abstract verbal communication.
Motor Function Impairments
(apraxia) resulting in problems with hand-eye and psychomotor
coordination which often manifests in clumsiness, slowed reflexes, and
mild disturbances in balance and gait.
Impairments (agnosia) that make it difficult to immediately
recognize familiar objects by touching, hearing, or seeing
Substance-induced Persisting Amnestic Disorder:
Memory impairments that make it difficult to learn & recall new
information, recall previously learned information, or recall past
events. The memory impairments cause problems with interpersonal
relationships, occupational functioning, or the performance of routine
acts of daily living. (American Psychiatric Association 1994
pp. 161 - 162)
Substance-induced Psychotic Disorder:
Difficulty maintaining orientation to person, place, time, and context
caused predominately by hallucinations and delusions. (American
Psychiatric Association 1994 pp. 310 - 315)
occur in any sensory modality causing people to see things that aren't
there such as poorly formed shapes or shadows to detailed objects and
persons (visual hallucinations); hear things such as annoying
poorly formed sounds to specific words and statements (auditory
hallucinations); feel things such as bugs crawling on them
(tactile hallucinations); smell things that aren't there
(olfactory hallucinations), taste things that aren't there
Delusions are strongly held beliefs not supported by evidence and not
affected by the presentation of evidence that demonstrates they are not
true. Delusions may vary from mild to extreme and may include a
variety of themes including: Beliefs about wellness when
when presented with evidence of the symptoms of illness; Beliefs
about normal functioning and the absence of problems when presented
with evidence of dysfunction and problems; Beliefs about past
accomplishes that are grandiose and exaggerated in the absence of evidence
or when presented with contradictory evidence; Beliefs about being
persecution when no such persecution exists; Beliefs of religious
significance such as being God or being in direct communication with
God or some other spiritual or religious being in the absence of evidence.
Substance-induced Mood Disorder: A
disturbance in mood characterized by either: depressed mood
marked by: diminished interest in all or most activities; diminished
ability to experience pleasure; manic mood marked by an
extreme elevated sense pleasure and excitement, an expansive response to
others, or extremely irritable reactions to others; or Manic
Depressive Swings marked by rapid and unpredictable swings between
depressed moods and manic moods. (American Psychiatric Association
1994 pp. 370 - 375)
Substance-induced Anxiety Disorder: A state
of excessive worry marked by a tendency to believe that negative
experiences will occur in the future, difficulty controlling or
distracting self from the worrying thoughts, restlessness or feeling
keyed up or on edge, being easily fatigued, difficulty concentrating,
having a tendency for the mind to go blank, irritability, severe muscle
tension, and sleep disturbances that include difficulty falling,
difficulty staying asleep, or restless unsatisfying sleep. (American
Psychiatric Association 1994 pp. 439 - 444)
Substance-induced Sexual Dysfunction: The
inability to perform sexually as a result of the effects of
intoxication, or withdrawal. (APA 1994 pp. 519 - 521)
Substance-induced Sleep Disorder: Substance-induced
Sleep Disorders (APA 1994 pp. 601-607) consist of difficulty with the
sleep-wake cycle that include: insomnia marked by difficulty
falling, difficulty staying asleep, or restless unsatisfying sleep (APA
1994 pp. 553 - 557); hypersomnia marked by excessive sleepiness
marked by difficulty staying awake (APA 1994 pp. 557 - 562); parasomnia
marked by the inappropriate activation of autonomic nervous system,
motor systems, or cognitive processes during sleep, specific sleep
stages, or sleep wake transitions such as nightmares, sleep terrors,
excessive tossing and turning, and sleep walking. (APA 1994 pp. pp. 579
Progressive Symptoms of Substance Dependence
Once substance dependence develops, a progressive series
of self-reinforcing symptoms begin to develop. Two models of the
progressive symptoms will be presented: (1) The DSM-IV
Progressive Symptom Model; and (2) The Biopsychosocial Progressive
DSM IV Progressive Symptom Model was developed by completing
a three step procedure:
1: Analyzing the DSM-IV criteria for substance use
2: Dividing specific criteria that contained more than one identifiable
symptom into separate symptoms,
3: Arranging the symptoms in a logical progression supported by
both face validity and studies of widely accepted models that sequence
addiction symptom development (Jellinek 1960; Glatt 1982; APA 1994,
Biopsychosocial Progressive Symptom Model was developed by
completing the following steps:
1: Reviewing past progressive symptom model (Jellinek 1960; Glatt
2: Reviewing recent related to models of addiction containing
biological, psychological, or social symptoms (Tarter et al 1988;
Tabakoff 1988; NIAAA 1996; NIAAA 1995);
3: Isolating specific symptoms from all models, grouping into
similar categories, and eliminating duplication; and
4: Integrating the newly identified symptoms into the The DSM-IV
Progressive Symptom Model in proper order of development.
DSM-IV Progressive Symptom Model
Increased Tolerance (DSM-IV Criteria #1): Tolerance is
defined by either: (1) a need for markedly increased amounts of
the substance to achieve intoxication or the desired effect; or (2) a
markedly diminished effect with continued use of the same amount of the
Withdrawal (DSM-IV Criteria
Biopsychosocial withdrawal symptoms consistent with the drugs being used
appear when the person attempts to stop using. The symptoms
disappear when the same or a closely related drug is taken.
Withdrawal (DSM-IV Criteria #2):
Using alcohol or drugs to make the symptoms of withdrawal
(dysphoria, agitation, depression, impaired mental functioning) go away.
Loss of Control Over Quantity (DSM-IV
Criteria #3): Using alcohol or drugs
in larger quantities than intended;
Loss of Control Over Duration (DSM-IV
Using alcohol or drugs for longer periods of time than intended.
Loss of Control Over Frequency (DSM-IV Criteria #
Using alcohol or drugs
Spent Using DSM-IV
Spending a Great deal of time getting ready to use alcohol or
other drugs, using, or recovering from the effects of using.
Neglect Of Life
Responsibilities (DSM-IV Criteria #6): Failing
to meet major life responsibilities because of intoxication, or
Neglect Of Life Activities
(DSM-IV Criteria #6): Neglecting or
given up work, social, or recreational activities because of alcohol or
Alcohol And Drug Relate
Problems (DSM-IV Criteria #7):
Have You Had Any Physical, Psychological, Or Social Problems That
Were Caused By Or Made Worse By Your Alcohol Or Drug Use?
Desire To Cut Down (DSM-IV Criteria #4):
The desire to control the use of the substance by using smaller
amount, using less frequently, or limiting time spent using.
Attempts To Cut Down (DSM-IV
Conscious attempts to control the use of the substance by using
smaller amount, using less frequently, or limiting time spent using.
Continued Use In
Spite Of Problems (DSM #7): Have
You Ever Continued To Use Alcohol Or Drugs In Spite Of Knowing That They
Were Causing Or Making Physical, Psychological, Or Social Problems
Biopsychosocial Progressive Symptom Model
1. Biological Reinforcement:
Biological reinforcement that promotes continued use of alcohol and
other drugs. (NIAAA 1996)
2. Tolerance: Progressive
tolerance that requires increased amounts to achieve the desired state
of reinforcement. (DSM-IV Criteria #1)
3. Withdrawal: Acute
& Post Acute Withdrawal Syndromes when substance use is stopped.
(DSM-IV Criteria #2)
4. Loss of Control: Inability
to control over the quantity of substances consumed and length of
substance use episodes.
5. Inability To Abstain:
Inability to maintain long-term abstinence.
6. Addiction Centered Lifestyle:
The development of an addiction-centered lifestyle. (DSM-IV Criteria
7. Addictive Lifestyle Losses:
Giving up previously valued lifestyle activities due to substance
use. (DSM-IV Criteria #6)
8. Progressive Substance-related Problems:
The development of progressive substance-induced biopsychosocial
problems. (DSM-IV Criteria #7)
9. Continued Use In Spite Of The Problems:
The pain caused by the problems creates craving for more drug use
rather than a desire to correct the problems.
With renewed drug use awareness of the problems recedes from
conscious awareness. (DSM-IV Criteria #7)
10. Biopsychosocial Deterioration:
Progressive physical, psychological and social deterioration as a
long as substance use continues which ends in serious physical illness.
Serious psychiatric illness, suicide, death, or involvement in
Characteristics of Substance Use Disorders
Use Disorders develop involuntarily. People do not develop progressive problems with alcohol and other
mind altering drugs because they willfully choose to do. Most choose to experiment with substance use as a result of
normal social and cultural pressure. Their personal risk factors create an involuntarily
biopsychosocial reaction to substance use that leads to the abuse of,
addiction to, and dependence upon the mind-altering substances.
2. Genetically Influenced:
Genetic factors influence but do not cause substance use
inherited predisposition must interact with developmental and
environmental risk factors for substance use disorders to develop. People with a strong genetic history of substance use
disorders are more susceptible to substance-related brain dysfunction
and hence more vulnerable to other psychosocial risk factors.
Many people have genetically inherited protective factors that
lower risk of abuse and dependence.
People are more likely to develop substance use disorders if they
are the product of a culture that supports frequent, heavy, and abusive
use of alcohol and drugs and have developed the following addictive
beliefs: Alcohol and drug
use is safe and it is good for me, not using is bad for me.
I must use alcohol and other drugs to function well and have a
good life. Without alcohol
and drugs there will be many important things that I won’t be able to
do. People who support my
substance use are my friends and people who oppose it are my enemies.
Symptoms that develop during active episodes of chemical use and include:
1. Urgency In Initial Consumption:
The rapid consumption of the substance to achieve the desired
2. Euphoria: A
unique state of well being caused when the drug of choice causes the
release of a flood of pleasure chemicals in the brain.
3. High Tolerance: Over
time it takes large quantities of the substance to produce the desired
4. State-dependent Memory:
What is learned during drug use is forgotten when abstinent.
5. Unpredictable Episodes of intoxication:
Although normally functioning well when using substances due to
high tolerance, periodic and progressively more frequent episodes of
rapid onset intoxication begin to occur causing a loss of behavioral
control and substance-related problems.
Symptoms that develop when substances are not used that create
dysphoria, pain, and problems.
Progressive Substance-induced Brain Dysfunction: The long-term use of mood-altering chemicals causes brain dysfunction
that disorganizes personality and causes social and occupational
This brain dysfunction is most severe in genetically predisposed
This brain dysfunction is present during periods of intoxication,
short-term or acute withdrawal, and long-term or post acute withdrawal,
and chronic residual symptoms of permanent brain chemistry dysfunction.
In the late stages of substance dependence many clients develop
substance-induced organic mental disorders which seriously impair their
ability to respond to psychological, behavioral, and social treatments.
As this substance-induced brain dysfunction becomes more severe it
causes difficulty in thinking clearly, managing feelings and emotions,
remembering things, sleeping restfully, recognizing and managing stress,
and psychomotor coordination. These symptoms often improve when mind-altering substances are
used and return during periods of abstinence.
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.
2. Progressive Substance-induced Personality Disorganization:
As Substance Use Disorders become more severe they cause
progressively more severe personality problems.
Definition of Personality:
Personality is the habitual way of thinking, feeling, acting, and
relating to others that develops in childhood.
Personality develops as a result of the interaction among
genetically inherited temperaments, the consequences of prenatal care
including parental substance use, and early developmental experiences in
the family of origin.
Perpetuation of Personality Style:
There is a strong tendency for childhood personality patterns
(both self-enhancing and self-defeating) to be unconsciously perpetuated
in patterns of adult living.
People raised in dysfunctional families often develop
self-defeating traits or personality disorders (which AA calls character
defects) that interfere with their ability to recover.
Personality Change: Although
core personality styles are firmly imprinted and resistant to change,
most people experience personality change over the course of their life
as a result of three processes: the
gradual development of personal maturity and as a result of life
experience, education, and reflection;
positive intense corrective emotional life experiences; and
negative traumatic life experiences.
Relationship Of Personality & Substance Use Disorders: Self-defeating personality traits and personality disorders do
not cause substance use disorders to occur
but they can affect the rate of progression and the response to
personality traits and personality disorders can cause: a more rapid progression of symptoms;
difficulty in recognizing addiction;
refusal to seek treatment in the early stages; difficulty benefiting from treatment;
an increased risk of relapse;
Personality & Brain Dysfunction:
Personality disorganization occurs because the substance-induced
brain dysfunction interferes with normal thinking, feeling, and acting.
All substance abusers will experience progressive personality
disorganization with regular and heavy use.
Substance Abusers with preexisting personality and mental
disorders will decompensate more rapidly than those with more healthy
and integrated personalities. Some of the personality disorganization is temporary and will
spontaneously subside with abstinence as the brain recovers from the
Other personality traits will become deeply habituated during the
addiction and will require treatment in order to subside.
Progressive Social Dysfunction:
Social dysfunction, including family, work, legal, and financial
problems, emerges as a consequence of brain dysfunction and resultant
personality disorganization. The
progression of social problems typical moves from a normally integrated
social life, to an alcohol and drug centered social life, to and
addiction and crime centered social life, to addictive isolation.
6. Denial: People with substance use disorders have difficulty
recognizing their problems with substances for a number of reasons:
They have misinformation the nature of mind altering substances and
They are immersed in an alcohol and drug centered culture that
glamorizes drinking and drug use, supports frequent, heavy, and abusive
use, and enables alcohol and drug-related problems; (3)
Their perceptions and memories of substance-related problems are
distorted as a result of intoxication and withdrawal; (4)
The develop progressive substance-induced brain chemistry
dysfunction that causes by impairments in perception, abstract reasoning
abilities, judgment, and impulse control; (5)
Progressive personality disorganization causes dramatic changes in
values, beliefs, mood, and behaviors and results in chaotic and
unpredictable shifts in mood and personality; (6)
There is a lack of available and socially acceptable and effectively
designed resources for assessment and early intervention. (7)
Family members lack knowledge about substance use disorders, effective
intervention strategies, and addiction-specific treatment resources to
support their intervention efforts; (8)
The criminalization of drug abuse by the current war on drugs policy
makes substances abusers and their families unwilling to place
themselves or loved ones at risk for incarceration by seeking treatment.
7. Tendency Toward Relapse:
Addiction is a chronic disease that has a tendency toward
relapse. Relapse is best
understood as the process of becoming dysfunctional in recovery that
ends in physical or emotional collapse, suicide, or self medication with
alcohol or drugs.
1. General Principles of
The most effective treatment programs recognize that effective
treatment is based upon the principles of treatment availability,
dignity & respect, voluntary & involuntary equivalence, and
Recovery With & Without Treatment:
The most effective treatment programs recognize that many if not
most people with substance use disorders will require proper treatment
and self-help group involvement for an appropriate duration of time in
order to recover. They also
recognize, however, that some people are able to resolve problems
related to substance use disorders without the benefit of professional
treatment or self-help group involvement.
Dignity and Respect:
The most effective treatment programs requires that all substance
abusers be treated with dignity and respect at all stages of the
treatment and recovery process.
Treatment needs to be readily available during all stages of
recovery and is available upon within a reasonable period of being
individuals with substance use disorders may be uncertain about entering
treatment, it is important to take advantage of opportunities when they
are ready to enter treatment. Potential treatment applicants can be lost
if treatment is not immediately available or is not readily accessible.
Voluntary & Involuntary Equivalence:
The most effective treatment programs recognize that treatment
does not need to be voluntary to be effective. Initial motivation, or
lack of it is not critical to treatment outcome.
Strong motivation can facilitate the treatment process, but
initial approaches in treatment can create such motivation even in
clients who are initially strongly resistant to the treatment process.
Sanctions or enticements in the family, employment setting, or criminal
justice system can increase significantly both treatment entry and
retention rates and the success of drug treatment interventions.
The motivational status at time of admission, however, is not
related to treatment outcome.
Manualized Treatment System:
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, the modalities in which the content is processed with
the problems of the client.
Alcohol & Drug Testing:
The most effective treatment programs recognize that alcohol and
drug testing can be an important adjunct to but not a replacement for
treatment. Since substance
use disorders are chronic and often relapsing conditions, lapses to drug
use can occur during treatment. The
appropriate objectives of alcohol and drug monitoring during treatment
To help the patient withstand urges to use drugs; and
To detect alcohol or drug use early so that individual's
treatment plan can be adjusted to permit an early intervention,
reevaluation of the client’s needs in treatment, and adjustment of the
treatment plan to better match the client’s needs.
The most effective treatment programs recognize that client
characteristics play an important role in predicting response to
substance abuse treatment and that any comparison of outcome rates
across treatment programs must take those differences into account.
1-7-1. Characteristics Associated With Positive Treatment Outcome:
The client characteristics associated with positive response to alcohol and drug treatment has been
associated with being: married, employed, of a high social class,
financially secure, socially active, well adjusted to work and marriage,
and having little history
of arrest. And low severity of psychiatric symptoms at admission
1-7-2. Characteristics Associated With Negative Treatment Outcome:
client characteristics associated with negative response to treatment
aggressiveness, high rates of attempted suicide, organic brain syndrome
sociopathic personality, and dual diagnosis (a psychiatric diagnosis and
a diagnosis of alcohol or drug abuse and
1-7-3. Characteristics Not Associated With Outcome:
Client characteristics not associated with treatment outcome are gender and the degree or level of
motivation at time of admission.
most effective treatment programs recognize that most appropriate goal
for the treatment of substance dependence is the development of a
personally meaningful lifestyle that involves productive functioning in
the family, workplace, and society.
This typical involves:
from alcohol and other mind altering drugs.
(At certain stages in the recovery process abstinence may not be
realistically possible. At
those times, effective programs provide harm reduction and motivational
counseling processes can then be used to prepare the client to accept
the goal of abstinence.)
A Structured Recovery Program:
The development of a structured recovery program that supports
abstinence and the development of a lifestyle centered around sober and
Repair of Biopsychosocial Damage:
Repair of the physical, psychological, and damage caused by the
substance use disorder.
Treatment of Coexisting Disorders:
The treatment of coexisting mental and personality disorders that
interfere with abstinence and responsible living.
Positive Personality & Lifestyle Change:
Personality and life style changes that support continued
Cognitive-Behavioral Therapy (CBT): The most effective
programs use addiction-focused cognitive-behavioral therapy that fpocus
upon each specific drug of abuse (Carroll 1998).
3-1-1. are among the most frequently evaluated psychosocial approaches
for the treatment of substance use disorders;
have a strong level of empirical support;
have been studied in regard to various types of substances including
tobacco, alcohol, cocaine, marijuana, opiates, and other types of
are more effective when compared with no-treatment controls;
are superior to or comparable to other treatment approaches
are effective in reducing the severity of relapses when they
enhance the durability of treatment effects;
are most effective for patients at higher levels of impairment along
such dimensions as psychopathology or dependence severity.
4. Developmental Recovery
The most effective treatment programs conceptualize recovery from
Substance Use Disorders as a long-term developmental process that
progresses through stages. To successfully complete the long-term recovery process often
requires multiple episodes of treatment. As with other chronic
illnesses, relapses to drug use can occur during or after successful
treatment episodes. Addicted individuals may require prolonged treatment
and multiple episodes of treatment to achieve long-term abstinence,
successfully progress through all stages of recovery, and achieve fully
restored biopsychosocial functioning. The stages of recovery are:
Stage 0 – Active Addiction (Precontemplation):
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 this stage
patients recognize that they are experiencing alcohol and drug related
problems and need to pursue abstinence as a life style goal in order to
resolve these problems;
Stage 2 – Stabilization: During this stage
patients recover from acute and post acute withdrawal and stabilize
their psychosocial life crisis;
Stage 3 – Early Recovery:
During this stage patients identify and learn how to
replace addictive thoughts, feelings, and behaviors with
sobriety-centered thoughts, feelings, and behaviors;
Stage 4 – Middle Recovery: During this stage
patients repair the life style damaged caused by the addiction and
develop a balanced and healthy life style;
Stage 5 – Late Recovery:
During this stage
patients resolve family of
origin issues which impair the quality of recovery and act as long-term
Stage 6 – Maintenance:
During this stage patients continue a program of growth
and development and maintain an active recovery program to assure that
they don't slip back into old addictive patterns.
Tendency Toward Relapse:
As with other chronic lifestyle related diseases, people with
Substance Use disorders have a tendency toward relapse.
Relapse does not indicate a treatment failure.
Relapse is best viewed as 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. This makes
intervention possible for some clients before alcohol or other drug use
begins. (Miller & Harris 2000)
The appropriate response to a relapse is stop the relapse quickly
by using a preplanned intervention,
stabilize the client in the appropriate level of care, assess the
factors that contributed to the relapse, revise the recovery plan, and
get the person back to working a personal recovery plan as quickly as
The most effective treatment matches each individual's particular
problems and needs to the type of treatment.
This involves the use of:
Addiction-focused Biopsychosocial Framework:
The most effective treatment attends to the multiple needs of the
individual, not just his or her drug use. To be effective, treatment
must address the individual's drug use and any associated medical,
psychological, social, vocational, and legal problems.
The most effective treatment of substance use disorders is
biopsychosocial in nature focusing both upon motivating the substance
abuser to stop using mind altering substances, self-evaluate their
substance use and its benefits and disadvantages, make a commitment to
abstinence, explore higher values that can provide meaning and purpose
to a sober life, and identify and resolve related personal and life
Comprehensive Assessment System:
The most effective treatment programs start with a comprehensive
assessment that evaluates the clients severity of addiction, profile the
presenting problems, identifies the current stage of recovery and
assesses other biopsychosocial conditions or disorders that are related
to successful recovery from addiction.
6-2-1 Detoxification: The
most effective treatment programs recognize that Medical detoxification
is only the first stage of addiction treatment and by itself does little
to change long-term drug use. Medical detoxification safely manages the
acute physical symptoms of withdrawal associated with stopping drug use.
While detoxification alone is rarely sufficient to help addicts achieve
long-term abstinence, for some individuals it is a strongly indicated
precursor to effective drug addiction treatment.
6- 2-2. Medical Problems Related To Substance Use Disorders:
The most effective treatment programs provide assessment for
medical problems that often coexist with substance use disorders
including HIV/AIDS, hepatitis B and C, tuberculosis and other infectious
diseases. When such
coexisting illnesses are present, counseling should be provided to help
patients modify or change behaviors that place themselves or others at
risk of infection, avoid high-risk behavior, and deal with the emotional
and practical issues of managing their illness.
6-2-3. Coexisting Psychiatric Disorders:
The most effective treatment programs recognize that addicted or
drug-abusing individuals with coexisting mental disorders should have
both disorders treated in an integrated way. Because addictive disorders
and mental disorders often occur in the same individual, patients
presenting for either condition should be assessed and treated for the
co-occurrence of the other type of disorder.
Appropriate Medication Management:
The most effective treatment programs recognize that:
6-3-1. Medications can be an important element in the treatment of
substance use disorders for many patients sufferring from severe
withdrawal or coexisting mental and emotional problems;
6-3-2. Appropriate caution must be exercised to avoid cross addiction,
6-3-3. Provide medication management as part of a comprehensive
treatment program that combines medication management with counseling,
other forms of behavioral therapies, and participation is self-help
Length of Treatment:
The most effective treatment programs recognize that substance
use disorders are chronic and lifestyle related health problems that
require consistent care long-term care.
As a result they keep clients in treatment for an adequate period
of time at a level of care appropriate to their current needs in
indicates that for most patients, the threshold of significant
improvement is reached at about 3 months in treatment. After this
threshold is reached, additional treatment can produce further progress
toward recovery. Because people often leave treatment prematurely,
programs should include strategies to engage and keep patients in
Levels Of Care: The
most effective treatment programs use a level of care system that
matches the client’s level of stability and needs in treatment to a
specific level of care including inpatient, residential, outpatient,
case management. Although
the primary focus of treatment is upon the delivery of long-term
outpatient services, effective treatment can increase and decrease the
intensity of the level of care based upon changes in the client’s
level of stability during treatment..
A Variety of Treatment Modalities:
The most effective treatment programs have a broad spectrum of
treatment modalities within each level of care that include education,
group therapy, individual therapy, and self-help groups. Patients are
matched to specific treatment modalities based upon their unique profile
of individual needs.
Self-help Program Participation:
The most effective treatment programs recognize that
participation in self-help support programs during and following
treatment often is helpful in maintaining abstinence.
The most effective treatment programs are staffed by
multidisciplinary treatment teams whose members develop close formal and
informal relationships with each and with the substance abusers they
treat. Patients are matched to specific members of the treatment team
based upon their unique profile of individual needs.
The most effective treatment programs coordinate and integrate
all aspects of treatment into an individualized treatment plan that
focuses upon developing a personal recovery program that involves a
schedule of professional, self-help, and personal recovery activities.
Continuing Assessment & Treatment Plan Updating: The
most effective treatment programs recognize that an individual's
treatment and services plan must be assessed continually and modified as
necessary to ensure that the plan meets the person's changing needs.
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Terence T. Gorski is
internationally recognized for his contributions to Relapse
Prevention Therapy. The scope of his work, however, extends far
beyond this. A skilled cognitive behavioral therapist with extensive
training in experiential therapies, Gorski has broad-based experience
and expertise in the chemical dependency, behavioral health, and
criminal justice fields.
To make his ideas and methods more
available, Gorski opened The CENAPS Corporation, a private training and
consultation firm of founded in 1982. CENAPS is committed to
providing the most advanced training and consultation in the chemical
dependency and behavioral health fields.
Gorski has also developed skills
training workshops and a series of low-cost
book, workbooks, pamphlets, audio and videotapes. He also works with
a team of trainers and
consultants who can assist individuals and programs to utilize his
ideas and methods.
Terry Gorski is available for personal
and program consultation, lecturing,
and clinical skills training workshops. He also routinely schedules
workshops, executive briefings, and personal growth experiences for
clinicians, program managers, and policymakers.
Mr. Gorski holds a
B.A. degree in psychology and sociology from Northeastern Illinois
University and an M.A. degree from Webster's College in St. Louis,
Missouri. He is a Senior
Certified Addiction Counselor In Illinois. He is a prolific author
who has published numerous books, pamphlets and articles. Mr.
Gorski routinely makes himself available for interviews, public
presentations, and consultant. He has presented lectures and
conducted workshops in the U.S., Canada, and Europe.
books, audio, and video tapes written and recommended by Terry Gorski
contact: Herald House - Independence Press, P.O. Box 390 Independence,
MO 64055. Telephone: 816-521-3015 0r 1-800-767-8181. His
publication website is www.relapse.org.
Gorski and other member of the GORSKI-CENAPS Team are Available To Train
& Consult On Areas Related To Spirituality in Recovery & Relapse
Gorski - CENAPS, 17900 Dixie Hwy, Homewood, IL
60430, 708-799-5000 www.tgorski.com,