CADC exam prep Ch 2 (Addiction Counselor’s Desk Reference)

Moral Model (Definition of Addiction)
– Dates to the 1850’s.
– Defines an addicted client as weak in character. Think “moral failure”.
– Based on the idea that individuals have free choice and are responsible for their behaviors. Think “morals that are aligned with God” and this approach has influenced public policy and the American judicial system.

Self-medication Model (Definition of Addiction)
– Originated in the 1960’s among psychoanalysts.
– Assumes that people self-medicate to cope with life problems. A person in emotional pain will self-medicate to find relief which may eventually lead to addiction.
-Self-medication hypothesis should be considered parallel with other approaches and not in competition with them.

Medical/Disease Model (Definition of Addiction)
– First proposed in 1810 by Dr. Benjamin Rush
– Addiction identified as a disease rather than a mental disorder or moral failure.
– Disease is identified as a severely harmful, potentially fatal condition that manifests itself in an irreversible loss of control over use of psychoactive substances. Disease may go into remission, no known “cure”, since the disease is progressive and often fatal, complete abstinence is the treatment goal. Think “addiction is a disease of the brain”.
– American Medical Association formally accepted this definition of addiction in 1945.
– Disease model accepted by World Health Organization (WHO), American Psychiatric Association (APA), American Society for Addiction Medicine (ASAM), National Association of Social Workers (NASC), & American Public Health (APH).

Spirituality Model (Definition of Addiction)
– Assumes that addictive disorder stem from a lack of spirituality, that is, being disconnected from a “Higher Power” (“the source of light, truth, love, and wellness”).
– AA, NA, etc derive some of their beliefs from this model and help members recover by developing a viable relationship with their “Higher Power”.

Impulse-Control Disorder (Definition of Addiction)
– relatively new definition.
– Assumes that either neurobiological or genetic deficiencies make a person unable to control and regulate impulsive behavior(s).
– Under certain conditions, such individuals will put themselves at risk and find temporary relief with self-destructive behaviors such as kleptomania, pyromania, and/or drug abuse.

Reward Deficiency and Neuro-physiological Adaption (Definition of Addiction)
– Assumes that chemical imbalance is manifested as one or more behavioral disorders called the “reward deficiency syndrome”.
– This disorder is linked by a common biological substrate, a “hard-wired system in the brain (consisting of cells and signaling molecules) that provides pleasure in the process of rewarding certain behaviors.”
– Supporters suggest that this reward deficiency syndrome may cause a predisposition, or vulnerability, to addiction that includes chemical substances, pathological gambling, sex, and other bx disorders.

Genetic Model (Definition of Addiction)
– Research over past 20 years indicated genetic predisposition in some individuals to substances of abuse.
– Some studies indicate 40% – 60% of an individual’s risk for an addiction to chemical substances (alcohol, cocaine, or opiates) is genetic.
– Growing number of genetic researchers now believe different classes of substances may be connected to unique genetic preference and may help account for the drug of choice.

Bio-medical model (Definition of Addiction)
– Introduced in 1990’s and draws from both the biological and behavioral sciences.
– “Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways that can persist long after the individual stops using them.”
– Once addiction impacts the brain, the client is driven behaviorally to support the demands made by the brain to prevent becoming ill from withdrawal.

Social Learning Model (Definition of Addiction)
– Assumes social reinforcement causes individuals to model the drug use behaviors of their parents, older siblings, and peers.
– Albert Bandura, social learning theorist, indicates 4 stages of social learning:
1. Attention – the individual makes a conscious cognitive choice to observe the desired behavior
2. Memory – the individual recalls what he has observed from the modeling
3. Imitation – the individual repeats the actions that she has observed
4. Motivation – the individual client must have some internal motivation for wanting to carry out the modeled behavior.

Erroneous Thought Patterns (Definition of Addiction)
– Assumes that illogical thinking underlies the addiction.
– Theorists believe that in order to helps addicted clients, counselors must challenge erroneous thinking, correct flawed thinking, and teach them how to reason correctly.
– EX: gambler who believes they have a “system” to beat video poker machine.

Biopsychosocial Model (Definition of Addiction)
– Developed in 1980’s.
– Assumes that addiction vulnerability is affected by the complex interaction between one’s physical status (functioning of the body), psychological state (how one views and perceives the world), and social dynamics (how and with whom one interacts).
– Allows for more flexibility in determining root cause and treatment.

Public Health Model (Definition of Addiction)
– Institute of Medicine (1989) defines addiction from a public health perspective, identifying 3 etiologic factors:
1. Agents – the psychoactive drugs
2. Hosts – individuals who differ in their genetic, physiological, behavioral, and sociocultural susceptibility to various forms of chemicals
3. Environment – the availability and accessibility of the agent.

Characteristics of Addiction
All addictions have generally 3 characteristics. Called the 3 C’s – Compulsive use, loss of Control, & Continued use despite adverse consequences. Client doesn’t have to exhibit all 3 but will happen problem with at least one.
-Tolerance and withdrawal.

Compulsive use
Has 3 elements:
1. Reinforcement – occurs when the addictive substance or behavior is first engaged. Being rewarded with pleasure and/or relief from pain and stress reinforces use. As use continues, tolerance develops and it takes larger doses of the substance or bx to obtain same levels of pleasure and relief.
2. Craving – body and brain send intense signals to brain that the drug or bx is needed. Using drugs on an ongoing basis alters the chemical balance of the brain. Withdrawal symptoms are unpleasant physical symptoms (the opposite of the drug effects) and may kick in when the drugs/bx’s are withheld. Psychological cravings related to experience of taking the drug or engaging in the bx can also occur.
3. Habit.

Loss of Control
Individuals suffering from addictions cannot predict or determine how much of the drug they will use or when they will use it. Once starting difficulty with stopping.
– This same loss of control applies to compulsive gambling, sex, binges.

Continued use despite adverse consequences
– Addictive bx’s have negative consequences, however, the pleasure/relief of substance/bx may outweigh the problems and a client may continue to use.

– When the drug is continually used, the body adapts to – and begins to tolerate – the drugs pharmacological effects. Thus, user needs more and more to get same pleasurable effect.
-2 types of tolerance:
1. Metabolic tolerance (pharmacokinetic tolerance) – when the body increases its efficiency in the breaking down chemicals for elimination
2. Pharmacodynamic tolerance (functional tolerance) – when the CNS becomes less sensitive to the effects of the drug of choice.

When drug use is stopped, user suffers from unpleasant effects that are usually the opposite of those induced by the chemical. May be life threatening for some.
– May create the rebound effect: “the characteristic of a drug to produce reverse effects when the effect of the drug has passed or the client no longer responds to it.”
– Alcohol withdrawal without medical assistance can escalate to the point where the client may experience delirium tremens (seizures, disorientation, and even death).

3. Types of Addictive Disorders
– Neuroscientists view addiction as a brain disorder expressed in compulsive bx’s; a condition caused by persistent changes in brain structure and function.
Includes not just mood-altering chemical substances but also behaviors such as compulsive gambling, sex, eating (although some believe eating is not an addiction), spending, and extreme work.

Brain & Psychoactive Drugs
– Brain’s normal circuits include a system – the brain reward system – that induces pleasurable feelings when stimulated. To regain these rewarding feelings, this circuit encourages a repeat of the behaviors that stimulate pleasurable feelings.
– All addictive drugs disrupt normal neurotransmission in the brain: by either changing the communication system by interfering with synaptic transmission, mimicking certain neurotransmitters and conveying false messages, and/or by blocking neurotransmitters and preventing real message from getting through.
– With a speed and intensity that greatly exceeds normality, these extremely pleasurable feelings lead some to seek them at any risk which can eventually lead to compulsive, “out of control”, and problematic bx’s if continued.

“False messengers” & “real messengers”
(pg 42).
Mimic the actions of natural brain chemicals while the “real messengers” some of which make people feel pleasure by activating their brain’s reward system.
-Drugs of abuse negatively impact regions of the brain by sending false messengers or by weakening or intensifying real messages.
– Drugs turn on the brain’s reward system with a potency that natural rewards can rarely match. “Drugs teach people to use more drugs.”
– Repeated drug use results in tolerance which increases the risk for physiological and perhaps psychological dependency.

Brain & Psychoactive Drugs (enlightening) quote
“The behavior of addicts is strongly influenced by the maladaptive learning that takes place as addiction develops. As a result, recovering from drug addiction does not mean returning to a condition like the one that existed before drug abuse began. Instead, addicts must grow into a new level of personal awareness, with new patterns of behaviors.”

Brain & Addictive Behaviors
– The term addiction (including neuroadaptation – i.e. biological processes of tolerance & withdrawals) also applies to behaviors such as pathological gambling, forms of sexual excess, pornography, eating excesses, overwork, compulsive buying, and other compulsive excesses.
– Human brain processes all positive rewards similarly, regardless of whether it comes from a chemical or behavior (gambling, sex, work, shopping, etc).
– Hence, those who become addicted do not necessarily crave a specific drug but rush of dopamine produced.
– Some chemicals or excessive experiences activate brain reward systems directly and dramatically (ie. bx & chemical are similar & provide too much reward for an individual’s neurobiology to handle). The ingestion of certain chemicals is accompanied by massive mood elevations and other affective changes and may lead to a reduction in other activities previously pleasurable. This is the same in which excessive behaviors activate reward mechanisms.
– Addictions occurs in constellations; that is, people addicted to one substance are often addicted to other substances and behaviors.

DSM IV-TR Substance abuse disorders
A maladaptive use of chemical substances leading to clinically significant outcomes or distress (“recurrent legal problems &/or failure to perform at work, school, home, or physically hazardous behaviors, such as driving when impaired.

DSM IV-TR Substance dependence disorders
Loss of control over how much a substance is used once begun, manifested by seven symptoms; tolerance; withdrawal, using more than was intended; unsuccessful efforts to control use; a great deal of time spent obtaining and using the substance; and continued use despite knowing that it causes problems.

DSM IV-TR Substance induced disorders
Manifesting the same symptoms as depression &/or mental health disorder, which symptoms, the direct result of using the substance, will cease shortly after discontinuing the substance.

Compulsive Gambling
– Is listed in the DSM IV-TR as an “impulse control disorder” and is grouped with pyromania, kleptomania, intermittent explosive disorder and trichotillomania. However, it is now placed in the DSM V in the “Addiction & Related Disorders” category.

Addictive Interaction Disorder
The 11 ways in which using and addictions impact one another.

Cross tolerance
A simultaneous increase in addictive behavior in two or more addictions or a transfer of a high level of addictive activity to a new addiction with little or no developmental sequence.

Withdrawal mediation
One addiction moderates, provides relief from, or prevents physical withdrawal symptoms from another.

One addiction replaces another with a majority of the emotional and behavioral features of the first.

Alternating addiction cycles
Addictions cycle back and forth in a patterned systemic way.

An addict uses one addiction to cover up for another, perhaps more problematic, addiction

Addictive rituals or behavior of one addiction serves as a ritual pattern to engage another addictive behavior

One addiction is used to accelerate, augment, or refine the effects of another addiction through simultaneous use

An addiction is used to medicate (soothe) shame or pain caused by another addiction or addictive bingeing

One addiction is used frequently to chronically to lower inhibitions for other forms of addictive acting out

Addictive behaviors are used to achieve certain effects that can only be achieved in combination

One addiction is used to substitute or deter the use of another addiction that is thought to be more destructive or socially unacceptable.

Initiation (Drug-use Stage)
Drug experimentation typically begins during adolescence, in social contexts during middle or high school. Usually in more of a social recreational context – teens very rarely start using alone.

Escalation (Drug-use Stage)
A time of increasing preoccupation with substances and more frequent socializing with other users. Intoxication is thought of as normal and fun – a healthy form of recreation. Variety of substances used is increased and users typically have little concern about drugs impact on health/future.

Maintenance (Drug-use Stage)
No longer recreational, more of a necessity. As tolerance increase, time is spent using to just “feel normal” and manage personal feelings with substances. Using becomes primary focus and housing, food, work, relationships, and other necessities are ignored or abandoned.

Discontinuation & Relapse (Drug-use Stage)
4. Discontinuation & Relapse: The stage of seeking help to stop using – sometimes forced (ex: incarceration), “hitting rock bottom”, family pressues, OD’s, and/or the revelation that the substances are not the solution but rather the problem. Some do it on their own others with significant treatment. Relapse is also a part of this stage as addiction is a chronic condition.

Recovery (Drug-use Stage)
Varies to each individual. For most, it is the cessation of all psychoactive substances with the recognition that substances were problem not solution. Grieving process of “losing” the drug lifestyle. Increase in healthier activities and networks. Can regain physical health but must grow emotionally as using stunted emotional process. Developmentally behind due to drug use as primary coping mechanism.

3 Stages of Recovery: (1) Early Stage Recovery
– Spanning first 6 months of sobriety, the risk of relapse is highest during this time. Mental clarity is impaired and so is physical health. Clients are beginning to develop new non-chemical ways of dealing with daily stressors. Building of social support networks. Can also experience the accompanying mood swings and depression that can derail treatment.

3 Stages of Recovery: (2) Middle Stage of Recovery
– 2nd 6 months of sobriety. Individuals struggle with the physical, social, and psychological adjustments of sobriety. Many emotions including grieving process (mourning loss of BF/good times enjoyed using drugs). Individuals begin to re-establish their ability to feel and to deal with their emotions without using drugs.

3 Stages of Recovery: (3) Late Stage Recovery
– Begins after roughly a year of sobriety. Individuals begin to gain confidence in new support systems and the psychosocial and (spiritual, emotional, etc) tools they have learned in treatment/recovery groups. Increased stability and continuous work reconnecting and reforming healthy relationships and activities.

Levels of Drug Use
Drug conditions, not stages. Individuals do not necessarily move predictably from one condition to another and may swing from one extreme to another.

Levels of Drug Use (1) Abstainers
– Roughly 1/3rd of all Americans abstain from using substances, some conscious (e.g. religious reasons) or other reasons due to horrible experiences from a using lifestyle (e.g. AA participants, 12-step participants).

Levels of Drug Use (2) Social Users
– Constitutes majority of people. Limit their intake of substances to social gathering where using is peripheral rather than the main purpose or attraction. Substances are seen simply as ways to enhance the pleasure of the gathering wile accomplishing other social goals. Ingestion intermittently, go long periods of time without it, quit at any time (*in control). No to little preoccupation with drugs or getting high.
– Research shows 20% appear to develop a more dependent relationship (with alcohol, for example).
– As much as 25% for marijuana users become dependent.
– 85% of cocaine, heroin, meth users over the long-term become dependent.

Levels of Drug Use (3) Drug Abusers
– Used substances typically in social settings but consumption is heavier and intoxication is usually the purpose of their get togethers. Use is sporadic, usually on weekends. Partying with other like-minded users is socially rewarding and a sign of acceptance.
-Depending on the drug, tolerance starts to develop. May increase in frequency, duration, and intensity of use.
-Motivators to misuse:
1. Coping strategy to avoid unwanted feelings
2. A way to change mood or personality (e.g. be more up and bubbly)
3. Escape unwilling obligations
4. Enhancement in social standing with others (e.g. to be “Cool”)
5. Enhancement of performance (e.g. stimulants for exams, downers to play mellow music, relaxation in stressful situations, etc).

Levels of Drug Use (4) Physically but Not Psychologically Dependent Users
– Inadvertently addicted to drugs prescribed by medical professional is an example of this type as they come to despise the prescribed drugs (opposite of psychological dependence) but their bodies gradually develop a tolerance, thus, must sometimes endure a detox/withdrawal symptoms.
– There may be an escalation in reward-pain ratio shifts and unpleasant/disruptive events in which user will want to quit.
– (“Hates drug”) Blame is on substances for spiraling decline.

Levels of Drug Use (5) Physically and Psychologically Dependent Users
– Highly dependent on substances as only coping mechanisms.
– Reward-pain ratio shifts, unpleasant/disruptive events accelerate, rather than discontinuing the using, the user increases the dosage, switches to other drugs, or try to titrate (or change it to) various substances.
-(“Loves” drug). Blame is not on substances for spiraling decline and consider substance solution, not problem. Continue to use despite deterioration in order to feel normal/survive.
– Research suggests this user can seldom be a “social user” again.
– Permanent, chronic chemical dependence.

Trans-Theoretical Model or Stages of (behavioral) Change
Believes client comes in with different levels of motivation and the clients motivation significantly influences behavioral change. So, counselor should match motivation level with an effective tx plan. Use Stages of Change model to assess client’s motivation level and create appropriate tx.
– Success is defined as both a behavioral change and any movement toward change (including shifts from one stage to another.

Stage of Change 1 – Precontemplation
– Clients do not perceive their actions as problematic.
– 4 R’s:
1. Reluctance – do not want to consider change (for whatever reason). The real or potential impact of problem is not yet apparent.
2. Rebellious – heavy investment in their behavior and making own decisions. Resistant to be told what to do.
3. Resigned – “given up” concerning the possibility of change and seem overwhelmed by the problem. Some have tried to control, cut back, or quit to no avail.
4. Rationalizing – “have all the answers”; plenty of reasons why behavior is not a problem or why particular behavior is a problem for others but not for them.

Stage of Change 2 – Contemplation
– Greater awareness of risks of present behaviors but still struggle with ambivalence.
– May realize there is a problem but feel that they can handle it.
– Often make a risk-reward analysis with counselor (pros & cons; decisional balance exercise).
– Utilize MI skills.

Stage of Change 3 – Preparation
– Clients agree there is a problem but are not yet 100% committed to the recovery process. Ambivalence is no longer an insurmountable barrier to change.
– Critical that clients not stay in this stage for longer than 30ish days as it is easy to slip back to Stage 2 or 1.
– Counselor’s goal is to move clients toward the action stage as fast as possible without pushing. Momentum in moving toward action can be achieved by having clients talk about potential plans. Help clients develop a firm, detailed action plan.

Stage of Change 4 – Action
– Clients are motivated to improve their lived by following a clearly defined action plan with goals leading to desired outcomes.
– With good action plan, client begins to experience successes, making adjustments along the way.
– Increase in hope, self-confidence, determination to not return to problem bx, and addiction-related losses begin to be restored.
– Counselors must create a manageable treatment plan with clear goals. Recovery contract with specified goals and rewards for achieving milestones.

Stage of Change 5 – Maintenance & Relapse Prevention
– Clients have taken action and are now learning the necessary skills to avoid relapse. The longer the client stays on course, the less chance of relapse.
– Ensure tx plan is appropriately revised and updated with new core skills.
– “Relapse often occurs when clients stop paying attention to the details that have kept them free from bx problems.

Stage of Change 6 – Termination
– Clients have developed core skills needed to move past their addiction and have developed new life habits.
– Counselors are to encourage the development of healthy activities in place of former addiction and planning ways to improve overall quality of one’s life.

Prevention Types & Principles
Two prevention models are used: 1. Traditional classification employed by decades by public health workers and 2. more recent classification proposed by the Institute of Medicine.

Traditional Classification – 1 Primary Prevention
– Implemented before a person begins using drugs with the intent to prevent the drug use completely or at least delay consumption.
– EX: educational seminars, reading materials, school instruction, community awareness programs (DARE), changes in laws/regulations to restrict access to drugs, etc.

Traditional Classification – 2 Secondary Prevention
– Implemented after a person has experimented with drugs with the objective of discouraging escalation into more frequent or habitual use.
– EX: strengthening families, helping parents become aware of signs/sx of use, medical staff intervention at first signs of use, harm reduction programs, public education to increase awareness about caring for drug-using person, etc.

Traditional Classification – 3 Tertiary Prevention
– Implemented after person’s drug use has become a problem with the goal of helping the person recover, or minimally, to reduce the harm resulting from use/keep addiction from worsening.
– EX: educating public about the long-term consequences of chemical addiction, educating people about needle exchange programs, etc.

Institute of Medicine Prevention Classification
– Based on operational classification of disease prevention with three parts – prevention, treatment, and maintenance.

Institute of Medicine Prevention Classification – Universal
– Focusing on large populations (national, local community, school, or neighborhood) with efforts seeking to prevent or delay illicit drug use.
EX: Creating a prevention program for all students at a given school/school district.

Institute of Medicine Prevention Classification – Selective
– Focus is on specific populations known to be at great risk for substance abuse
– EX: targeting children of users or “poor school achievers”.

Institute of Medicine Prevention Classification – Indicated
– Interventions directed at those who have already experimented with drugs or who exhibit other risk-related bxs.
– EX: Project STAR; Adolescent Alcohol Prevention Trial. Other examples can be reviewed on NIDA.

Prevention Principles
Typically focus on 3 elements:
1. Person- prior drug use, skills, physiological reactions, and perceptions.
2. Situation – peer influence, family influence, opportunity, and social norms. One of the most effective target areas.
3. Environment – access, media impact, schools, and community policies, and financial factors. One of the most effective target areas.
– Research is ongoing concerning what constitutes effective prevention message presentation and content.
– For optimal success, should include: flexibility scheduling, reduction of initial time commitment, active involvement of both parents and peers, multiple positive rewards aligned to the target population (free food coupons, refreshments, and child care).

Prevention Principle Risk Factors – Community
Access to drugs and firearms, community laws, and norms favorable toward drug use, crime, media portrayals of violence, transition & mobility, low neighborhood attachment and community disorganization, “extreme” economic deprivation.

Prevention Principle Risk Factors – Family
Family history of problem behaviors, family management problems, family conflict, favorable parental attitude, involvement in problem bx’s.

Prevention Principle Risk Factors – School
Early & persistent antisocial behavior, academic failure beginning in late elementary school, and lack of commitment to school.

Prevention Principle Risk Factors – Individual/peer
Alientation, rebelliousness, friends who engage in the problem behavior, favorable attitude toward the problem behavior, early initiation.

Prevention Principles Research
This should include (among others):
1. Should target all forms of drug use
2. Should include skills to resist drugs when offered, strengthen personal commitments against drug use, and increase social competency.
3. Should include an instruction component for parents for other caregivers that reinforces what the children are learning (facts about drugs and harmful effects).

Relapse Prevention
Recovery typically defined as abstinence from mood-altering substances plus a full return to biopsychosocial function. Involves 6 stages

Relapse Prevention Stage 1
Abstaining from alcohol and other drugs.

Relapse Prevention Stage 2
Separating from people, places, and things that promote the use of alcohol or drugs, and establishing a social network that supports recovery.

Relapse Prevention Stage 3
Stopping self-defeating behaviors that prevent awareness of painful feelings and irrational thoughts.

Relapse Prevention Stage 4
Learning how to manage feelings and emotions responsibly without resorting to compulsive bx or the use of alcohol or drugs.

Relapse Prevention Stage 5
Learning to change addictive thinking patterns that create painful feelings and self-defeating behaviors.

Relapse Prevention Stage 6
Identifying and changing the mistaken core beliefs about oneself, others, and the world that promote irrational thinking.

Purpose of relapse prevention
Relapse is considered the return to a familiar dysfunction lifestyle, typically involving renewed dependence on chemical use, physical or emotional collapse or suicide. Usually experiences progressively increasing distress leading to physical or emotional collapse.
– Helps to prevent a “slip” (one incident) from becoming a full-blown relapse.
– As many as half of those in recovery relapse within the first 3 months.
– Involves helping recovering clients recognize warning signs of relapse.

Observable warning signs of relapse
– Being in the presence of drugs or alcohol, drug or alcohol users, or places where chemicals are used or bought. (*Hmmm…)
– Painful feelings (sadness, loneliness, guilt, fear, anxiety, and especially anger).
– Positive feelings, a cause for celebration
– Boredom
– Getting high on any drug
– Physical pain
– Listening to drinking/drugging “war stories” and dwelling on getting high
– Suddenly having a lot of cash
– Using Rx drugs that produce a high even if used properly
– Complacency, believing there is no longer cause to worry

Marlatt & Gordon’s Relapse Prevention Model
– Rooted in social learning theory and cognitive psychology. 1978-2000.
– 1980. Classified high-risk situations into categories; the three named most frequently accounted for 3/4’s of the relapses of clients:
1. Negative emotional states
2. Social pressure
3. Interpersonal conflict

Marlatt & Gordon’s RP Model
– Helps client:
1. Anticipate and identify high-risk situations
2. Develop skills to effectively deal with those situations
3. Confidently expect that using these skills will result in a positive outcome
– Also helps clients minimize damage by reacting quickly and effectively, reframing it as a slip, an unfortunate but isolated incident rather than a confirmation of a deep inability to recover.

Gorski’s CENAPS Relapse Model
– Grounded in CBT pschology, involves 6 stages:
6. Maintenance: Individual recognizes a need for continued growth and for balanced living.

Gorski’s relapse model stage 1
Transition: The individual recognizes problems but tries to surmount them by controlling his or her substance use.

Gorski’s relapse model stage 2
Stabilization: The individual decides to refrain from substance use completely and recuperates over an extended length of time (6-18 months)

Gorski’s relapse model stage 3
Early recovery: The individual becomes comfortable with being abstinent.

Gorski’s relapse model stage 4
Middle recovery: The individual repairs past damage caused by his or her substance use and develops a balanced lifestyle.

Gorski’s relapse model stage 5
Late recovery: Individual overcomes barriers to healthy living that stem from childhood experiences.

Gorski’s relapse model stage 6
Maintenance: Individual recognizes a need for continued growth and for balanced living.

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