ACKNOWLEDGMENTS 

This publication contains information on various drug abuse counseling approaches, written by 
representatives of many well-known treatment programs. Although the counseling approaches 
included are used in some of the best known and most respected treatment programs in this 
country, it has not been determined whether all of these counseling models are equally effective. 
These various approaches are presented in an identical outline form so that the reader can compare 
and contrast the many treatment models described and learn more about the roles of the counselor 
and subject in a particular model. 

COPYRIGHT STATUS 

All material in this volume is in the public domain and may be used or reproduced without 
permission from the National Institute on Drug Abuse (NIDA) or the authors. Citation of the 
source is appreciated. 

DISCLAIMER 

Opinions expressed in this volume are those of the authors and do not necessarily reflect the 
opinions or official policy of NIDA or any other part of the U.S. Department of Health and Human 
Services. 

The U.S. Government does not endorse or favor any specific commercial product or company. 
Trade, proprietary, or company names appearing in this publication are used only because they are 
considered essential in the context of the models reported herein. 

PUBLIC DOMAIN NOTICE 

All material appearing in this report is in the public domain and may be reproduced without 
permission from the National Institute on Drug Abuse or the authors. Citation of the source is 
appreciated. 

National Institute on Drug Abuse 
NIH Publication No. 00-4151 
Printed July 2000 


CONTENTS 

Introduction and Overview .........................................................1 


John J. Boren, Lisa Simon Onken, and Kathleen M. Carroll 

Dual Disorders Recovery Counseling ..................................................5 


Dennis C. Daley 

The CENAPS® Model of Relapse Prevention Therapy (CMRPT®) ............................. 23 


Terence T. Gorski 

The Living In Balance Counseling Approach............................................ 39 


Jeffrey A. Hoffman, Ben Jones, Barry D. Caudill, Dale W. Mayo, and Kathleen A. Mack 

Treatment of Dually Diagnosed Adolescents: The Individual Therapeutic Alliance Within a Day 
Treatment Model............................................................... 61 

Elizabeth Driscoll Jorgensen and Richard Salwen 

Description of an Addiction Counseling Approach........................................ 81 


Delinda Mercer 

Description of the Solution-Focused Brief Therapy Approach to Problem Drinking ................ . 91 


Scott D. Miller 

Motivational Enhancement Therapy: Description of Counseling Approach ...................... . 99 


William R. Miller 

Twelve-Step Facilitation .........................................................107 


Joseph Nowinski 

Minnesota Model: Description of Counseling Approach................................... 117 


Patricia Owen 

A Counseling Approach ......................................................... 127 


Fred Sipe 

A Psychotherapeutic and Skills-Training Approach to the Treatment of Drug Addiction ............. 139 


Arnold M. Washton 


Dual Disorders Recovery Counseling 


Dennis C. Daley 

1. 
OVERVIEW, DESCRIPTION, AND 
RATIONALE 
1.1 General Description of Approach 
Dual disorders recovery counseling (DDRC) 
is an integrated approach to treatment of patients 
with drug use disorders and comorbid psychiatric 
disorders. The DDRC model, which integrates 
individual and group addiction counseling 
approaches with psychiatric interventions, 
attempts to balance the focus of treatment so that 
both the patient’s addiction and psychiatric issues 
are addressed. 

The DDRC model is based on the assumption that 
there are several treatment phases that patients 
may go through. These phases are rough 
guidelines delineating some typical issues patients 
deal with and include: 

Phase 1—Engagement and Stabilization. In 
this phase, patients are persuaded, motivated, or 
involuntarily committed to treatment. The main 
goal of this phase is to help stabilize the acute 
symptoms of the psychiatric illness and/or the drug 
use disorder. Another important goal is to 
motivate patients to continue in treatment once the 
acute crisis is stabilized or the involuntary 
commitment expires. Dealing with ambivalence 
regarding recovery, working through denial of 
either or both illnesses, and becoming motivated 
for continued care are other important goals 
during this phase. 

This phase usually takes several weeks, but for 
some patients it takes longer to become engaged 
in recovery and to stabilize from acute effects of 
their dual disorders. 

Phase 2—Early Recovery. This phase 
involves learning to cope with desires to use 
chemicals; avoiding or coping with people, places, 
and things that represent high-risk addiction 
relapse factors; learning to cope with psychiatric 
symptoms; getting involved in support groups, such 
as Alcoholics Anonymous (AA), Narcotics 
Anonymous (NA), Cocaine Anonymous (CA), 
Rational Recovery (RR), Dual Recovery 
Anonymous, or mental health support groups; 
getting the family involved (if indicated); beginning 
to build structure into life; and identifying problems 
to work on in recovery. 

This phase roughly involves the first 3 months 
following stabilization. However, some patients 
take much longer in this phase because they do 
not comply with treatment, continue to abuse 
drugs, experience exacerbations of psychiatric 
symptomology, or experience serious psychosocial 
problems or crises. 

Phase 3—Middle Recovery. In this phase, 
patients continue working on issues from the 
previous phase as needed. In addition, patients 
learn to develop or improve coping skills to deal 
with intrapersonal and interpersonal issues. 
Examples of intrapersonal skills include coping 
with negative affect (anger, depression, emptiness, 
anxiety) and coping with maladaptive beliefs or 
thinking. Interpersonal issues that may be 
addressed during this phase include making 
amends, improving communication or relationship 
skills, and further developing social and recovery 
support systems. This phase also focuses on 
helping patients cope with persistent symptoms of 
psychiatric illness; drug use lapses, relapses, or 
setbacks; and crises related to the psychiatric 
disorder. It also focuses on helping identify and 


manage relapse warning signs and high-risk 
relapse factors related to either illness. 

The middle recovery phase involves months 4 
through 12, although some patients never get 
much beyond early recovery even after a long 
time in treatment. Patients who are treated for an 
initial acute episode of psychiatric illness with 
pharmacotherapy in addition to DDRC and who 
do not have a recurrent or persistent mental illness 
may be tapered off medications during this phase. 
Patients are usually not tapered off medications 
until they have several months or longer of 
significant improvement in psychiatric 
symptomology. 

Phase 4—Late Recovery. This phase, also 
referred to as the “maintenance phase” of 
recovery, involves continued work on issues 
addressed in the middle phase of recovery and 
work on other clinical issues that emerge. 
Important intrapersonal or interpersonal issues 
may be explored in greater depth during this phase 
for patients who have continued abstinence and 
remained relatively free of major psychiatric 
symptoms. 

This phase continues beyond year 1. Many 
patients with chronic or persistent forms of 
psychiatric illness (e.g., schizophrenia, bipolar 
disease, recurrent major depression), or severe 
personality disorders such as borderline 
personality disorder, often continue active 
involvement in treatment. Treatment during this 
phase may involve maintenance pharmacotherapy, 
supportive DDRC counseling, or some specific 
form of psychotherapy (e.g., interpersonal 
psychotherapy). Involvement in support groups 
continues during this phase of recovery as well. 

1.2 Goals and Objectives of Approach 
The goals of this counseling model are: 

1. 
Achieving and maintaining abstinence from 
alcohol or other drugs of abuse or, for 
patients unable or unwilling to work toward 
total abstinence, reducing the amount and 
frequency of use and concomitant 
biopsychosocial sequelae associated with 
drug use disorders. 

2. 
Stabilizing acute psychiatric symptoms. 
3. 
Resolving or reducing problems and 
improving physical, emotional, social, family, 
interpersonal, occupational, academic, 
spiritual, financial, and legal functioning. 
4. 
Working toward positive lifestyle change. 
5. 
Early intervention in the process of relapse to 
either the addiction or the psychiatric 
disorder. 
1.3 Theoretical Rationale/Mechanism of 
Action 
The DDRC counseling approach involves a 
broad range of interventions: 

1. 
Motivating patients to seek detoxification or 
inpatient treatment if symptoms warrant, and 
sometimes facilitating an involuntary 
commitment for psychiatric care. 
2. 
Educating patients about psychiatric illness, 
addictive illness, treatment, and the recovery 
process. 
3. 
Supporting patients’ efforts at recovery and 
providing a sense of hope regarding positive 
change. 
4. 
Referring patients for other needed services 
(case management, medical, social, 
vocational, economic needs). 
5. 
Helping patients increase self-awareness so 
that information regarding dual disorders can 
be personalized. 
6. 
Helping patients identify problems and areas 
of change. 

7. 
8. 
Helping patients develop and improve 
problemsolving ability and develop recovery 
coping skills. 
Facilitating pharmacotherapy evaluation and 
compliance. (This requires close 
collaboration with the team psychiatrist.) 
1.4 Agent of Change 
The DDRC model assumes that change may 
occur as a result of the patient-counselor 
relationship and the team relationship (i.e., 
counselor, psychiatrist, psychologist, nurse, or 
other professionals such as case manager or 
family therapist). A positive therapeutic alliance is 
seen as critical in helping patients become 
involved and stay involved in the recovery 
process. Community support systems, 
professional treatment groups, and self-help 
programs also serve as possible agents of positive 
change for dually diagnosed patients. For the 
more chronically and persistently mentally ill 
patients, a case manager may also function as an 
important agent in the change process. 
Although patients have to work on a number of 
intrapersonal and interpersonal issues as part of 
long-term recovery, medications can facilitate this 
process by attenuating acute symptoms, improving 
mood, or improving cognitive abilities or impulse 
control. Thus, medications may eliminate or 
reduce symptoms as well as help patients become 
more able to address problems during counseling 
sessions. A severely depressed patient may be 
unable to focus on learning cognitive or behavioral 
interventions until he or she experiences a certain 
degree of remission from symptoms of depression; 
a floridly psychotic patient will not be able to focus 
on abstinence from drugs until the psychotic 
symptoms are under control. 
1.5 Conception of Drug Abuse/ Addiction, 
Causative Factors 
Both psychiatric and addictive illnesses are 
viewed as biopsychosocial disorders. These 
disorders or diseases are caused or maintained by 
a variety of biological, psychological, and 
cultural/social factors. The degree of influence of 
specific factors may vary among psychiatric 
disorders. 
This DDRC model assumes that there are several 
possible relationships between psychiatric illness 
and addiction (Daley et al. 1993; Meyer 1986). 


 1. Axis I and Axis II psychopathology may 
serve as a risk factor for addictive disorders 
(e.g., the odds of having an addictive disorder 
among individuals with a mental illness is 2.7 
according to the National Institute of Mental 
Health’s Epidemiologic Catchment Area 
[ECA] survey). 
2. Some psychiatric patients may be more 
vulnerable than others to the adverse effects 
of alcohol or other drugs. 
3. Addiction may serve as a risk factor for 
psychiatric illness (e.g., the odds of having a 
psychiatric disorder among those with a drug 
use disorder is 4.5 according to the ECA 
survey). 
4. The use of drugs can precipitate an 
underlying psychiatric condition (e.g., PCP or 
cocaine use may trigger a first manic episode 
in a vulnerable individual). 
5. Psychopathology may modify the course of 
an addictive disorder in terms of: 
a. 
Rapidity of course (earlier age 
depressives experience addiction 
problems earlier; male-limited alcoholics 
[25 percent] with antisocial behaviors 
have earlier onset of addiction compared 
with milieu-limited alcoholics [Cloninger 
1987]). 
b. 
Response to treatment (patients with 
antisocial or borderline personality 
disorder often drop out of treatment 
early). 
c. 
Symptom picture and long-term outcome 
(high psychiatric severity patients as 
measured by the Addiction Severity Index 
(ASI) do worse than low psychiatric 
severity patients; there is a strong 
association between relapse and 
psychiatric impairment among opiate 
addicts and some association between 
relapse and psychiatric impairment among 
alcoholics [Catalano et al. 1988; McLellan 
et al. 1985]).

 6. 
Psychiatric symptoms may develop in the 
course of chronic intoxications (e.g., 
psychosis may follow PCP use or chronic 
stimulant use; suicidal tendencies and 
depression may follow a cocaine crash). 
7. 
Psychiatric symptoms may emerge as a 
consequence of chronic use of drugs or a 
relapse (e.g., depression may be caused by 
an awareness of the losses associated with 
addiction; depression may follow a drug or 
alcohol relapse). 
8. 
Drug-using behavior and psychopathological 
symptoms (whether antecedent or 
consequent) will become meaningfully linked 
over the course of time. 
9. 
The addictive disorder and the psychiatric 
disorder can develop at different points in 
time and not be linked (e.g., a bipolar patient 
may become hooked on drugs years after 
being stable from a manic disorder; an 
alcoholic may develop panic disorder or major 
depression long after being sober). 
10. 
Symptoms of one disorder can contribute to 
relapse of the other disorder (e.g., increased 
anxiety or hallucinations may lead the patient 
to alcohol or other drug use to ameliorate 
symptoms; a cocaine or alcohol binge may 
lead to depressive symptoms). 
2. 
CONTRAST TO OTHER COUNSELING 
APPROACHES 
2.1 
Most Similar Counseling Approaches 
The DDRC model is most similar to various 
aspects of several models of treatment used in 
addiction counseling, mental health counseling, or 


both. These include individual and group addiction 
recovery models, the psychoeducational (PE) 
model, the relapse prevention (RP) model, the 
cognitive-behavioral model, and the interpersonal 
model. 

2.2 
Most Dissimilar Counseling 
Approaches 
The DDRC model is dissimilar to the various 
forms of dynamic therapies. 

3. FORMAT 
3.1 
Modalities of Treatment 
The DDRC model can be used in a variety 
of group treatments and in individual treatment. It 
can also be adapted to family treatment. 

3.2 
Ideal Treatment Setting 
The DDRC model was primarily developed 
for use in a mental health or dual disorders 
treatment setting. It can be used throughout the 
continuum of care in inpatient, other residential, 
partial hospital, and outpatient settings. The 
specific areas of focus will depend on each 
patient’s presenting problems and symptoms and 
the treatment setting. Certain aspects of this 
model could be adapted and used in addiction 
treatment settings provided that appropriate 
training, supervision, and consultation are available 
for the counselor. 

3.3 
Duration of Treatment 
Acute inpatient dual-diagnosis treatment 
usually lasts up to 3 weeks. Longer term specialty 
residential treatment programs may last from 
several months to a year or more. Partial 
hospitalization programs usually last from 6 to 
12 months. Outpatient treatment lasts 6 months or 
longer. Recurrent conditions, such as certain 
depressive disorders and bipolar illness, as well as 
persistent mental illness such as schizophrenia, 
typically require ongoing participation in 
maintenance pharmacotherapy and some type of 
supportive counseling. 

3.4 
Compatibility With Other Treatments 
The DDRC model is very compatible with 
pharmacotherapy and family treatment. Many 
patients require medication to treat psychiatric 
symptoms. Therefore, medication compliance, the 
perception of taking medications as a recovering 
alcoholic or addict, and potential adverse effects 
of alcohol or other drugs on medication efficacy 
are important issues to discuss with the patient. 
Family participation in assessment and treatment 
is viewed as important and compatible with the 
DDRC model. The family can: 

1. 
Help provide important information in the 
assessment process. 
2. 
Provide support to the recovering patient. 
3. 
Address their own questions, concerns, and 
reactions to coping with the dually diagnosed 
patient. 
4. 
Address their own problems and issues in 
treatment sessions or self-help programs. 
5. 
Help identify early signs of addiction relapse 
or psychiatric recurrence and point these out 
to the recovering dually diagnosed family 
member. 
A combination of family PE programs, family 
counseling sessions, and family support programs 
can be used to help families. Referrals for 
assessment of serious problems (psychiatric, drug 
abuse, behavioral) among specific family members 
can also be initiated as necessary (e.g., a child of 
a patient who is suicidal, very depressed, or 
getting into trouble at school can be referred for a 
psychiatric evaluation). 

3.5 
Role of Self-Help Programs 
Self-help programs are very important in the 
DDRC model of treatment. All patients are 
educated regarding self-help programs and linked 
up to specific programs. The self-help programs 
recommended may include any of the following 


for a given patient: AA, NA, CA, and other 
addiction support groups such as RR or Women 
for Sobriety; dual-recovery support groups; and 
mental health support groups. However, this 
model does not assume that a patient cannot 
recover without involvement in a 12-step group or 
that failure to attend 12-step groups is a sign of 
resistance. The DDRC model also assumes that 
some patients may use some of the tools of 
recovery of self-help programs even if they do not 
attend meetings. Sponsorship, recovery literature, 
slogans, and recovery clubs are also seen as very 
helpful aspects of recovery for dually diagnosed 
patients. 

4. COUNSELOR CHARACTERISTICS 
AND TRAINING 
4.1 Educational Requirements 
The educational requirements are variable for 
inpatient staff and depend on the professional 
discipline’s requirements. Formal education of 
inpatient staff include M.D., Ph.D., master’s, 
bachelor’s, and associate degrees. Training in 
fields such as nursing may vary as well and 
include M.S.N., B.S.N., R.N., and L.P.N. 
Outpatient therapists tend to have at least a 
master’s degree or higher and function more 
autonomously than inpatient staff. 

4.2 Training, Credentials, and Experience 
Required 
To effectively provide counseling services to 
dually diagnosed patients, the counselor needs to 
have a broad knowledge of assessment and 
treatment of dual disorders. Specific areas with 
which the counselor should be familiar, at a 
minimum, include the following:

 1. Psychiatric illnesses (types, causes, 
symptoms, and effects). 
2. Drug use disorders (trends in drug abuse; 
types and effects of various drugs; causes, 
symptoms, and effects of addiction). 
3. 
The relationship between the psychiatric 
illness and drug use. 
4. 
The recovery process for dual disorders. 
5. 
Self-help programs (for addiction, mental 
health disorders, and dual disorders). 
6. 
Family issues in treatment and recovery. 
7. 
Relapse (precipitants, warning signs, and RP 
strategies for both disorders). 
8. 
Specialized psychosocial treatment 
approaches for various psychiatric disorders 
(e.g., treatments for posttraumatic stress 
disorder, obsessive-compulsive disorder). 
9. 
Pharmacotherapy. 
10. 
The continuum of care (for both addiction 
and psychiatric illnesses). 
11. 
Local community resources. 
12. 
The process of involuntary hospitalization. 
13. 
Motivational counseling strategies. 
14. 
Ways to deal with ambivalent patients and 
those who do not want help. 
15. 
Strategies to deal with refractory or 
treatment-resistant patients with chronic 
forms of mental illness. 
16. 
How to use bibliotherapeutic assignments to 
facilitate the patient’s recovery. 
The counselor must be able to develop a 
therapeutic alliance with a broad range of patients 
who manifest many different disorders and 
differing abilities to utilize professional treatment. 
This requires awareness of the counselor’s own 
issues, biases, limitations, and strengths, as well as 
the counselor’s willingness to examine his or her 
own reactions to different patients. 


The counselor needs to be able to effectively and problems. The counselor’s behaviors may 
network with other service providers since many include any of the following:

of these dually diagnosed patients have multiple 
psychosocial needs and problems. Because crises 
often arise, the counselor must also be conversant 
with crisis intervention approaches. The ability to 
work with a team is also essential in all treatment 
contexts. 

Experience with addicts and mental health patients 
is the ideal. However, if a counselor is trained in 
one field and has access to additional training and 
supervision in another, it is possible to expand 
knowledge and skills and work effectively with 
dually diagnosed patients. 

4.3 Counselor’s Recovery Status 
If a counselor has the training, knowledge, 
and experiential background in working with 
psychiatric patients and with addicts, a personal 
history of recovery can be helpful. Although self-
disclosure is sometimes appropriate, in general, the 
counselor providing treatment should share less of 
his or her own recovery experience than is 
typically shared in the more traditional addiction 
counseling model. 

4.4 Ideal Personal Characteristics of 
Counselor 
Hope and optimism for the patient’s 
recovery; a high degree of empathy, patience, and 
tolerance; flexibility; an ability to enjoy working 
with difficult patients; a realistic perspective on 
change and steps toward success; a low need to 
control the patient; an ability to engage the patient 
yet be able to detach; and an ability to utilize a 
multiplicity of treatment interventions rather than 
relying on a single way of counseling are 
important characteristics and qualities that 
counselors need. 

4.5 Counselor’s Behaviors Prescribed 
The DDRC approach requires a broad range 
of behaviors on the part of the counselor. Specific 
behaviors are mediated by the severity of the 
patient’s symptoms and his or her related needs 

1. 
Providing information and education. 
2. 
Challenging denial and self-destructive 
behaviors. (Confrontation is modified to take 
into account the patient’s ego strength and 
ability to tolerate confrontation.) 
3. 
Providing realistic feedback on problems and 
progress in treatment. 
4. 
Encouraging and monitoring abstinence. 
5. 
Helping the patient get involved in self-help 
groups. 
6. 
Helping the patient identify, prioritize, and 
work on problems and recovery issues. 
7. 
Monitoring addiction recovery issues. 
8. 
Monitoring target psychiatric symptoms 
(suicidality, mood symptoms, thought disorder 
symptoms, or problem behaviors). 
9. 
Helping the patient develop specific RP skills 
(e.g., coping with alcohol or other drug 
cravings, refusing offers to get high, 
challenging faulty thinking, coping with 
negative affect, improving interpersonal 
behaviors, managing relapse warning signs). 
10. 
Advocating on behalf of the patient and 
facilitating inpatient admission when needed. 
11. 
Facilitating the use of community resources 
or services. 
12. 
Developing therapeutic assignments aimed at 
helping the patient reach a goal or make a 
specific change. 
13. 
Following up when a patient fails to follow 
through with treatment. 

14. 
Offering support, encouragement, and 
outreach. 
4.6 Counselor’s Behaviors Proscribed 
The DDRC counselor does not typically 
interpret the patient’s behaviors or motivation. 
The focus is more on understanding and coping 
with practical issues related to the dual disorders 
and current functioning. The counselor avoids 
extensive exploration of past traumas during the 
early phase of recovery because this can lead to 
avoidance of addressing the drug use disorder and 
can increase the patient’s anxiety. The DDRC 
counselor also minimizes time spent on coaddiction 
issues since this can deflect from the drug use 
problem and raise anxiety. 

Harsh confrontation is avoided because it can 
adversely impact on the patient’s sense of self and 
can drive the patient away from treatment. 
Confrontation can be used, but it should be done in 
a caring, nonjudgmental, nonpunitive, and reality-
oriented manner. 

4.7 Recommended Supervision 
The goals of supervision are to help the 
counselor: 

1. 
Increase knowledge of dual disorders 
counseling. 
2. 
Improve special counseling skills. 
3. 
Deal with personal issues or reactions that 
impede therapeutic alliance or progress (e.g., 
anger toward a patient who relapses, 
negative reactions to a patient with a 
personality disorder). 
4. 
Use personal strengths in the counseling 
process (e.g., personal experiences, humor). 
5. 
Maintain a reasonable therapeutic focus on 
the patient’s addiction and mental health 
disorder. 
6. 
Determine strategies to work through 
impasses in counseling. 
A variety of formats can be used in supervising 
the DDRC approach: 

1. 
Joint discussion of individual counseling 
cases, family sessions, or group sessions. 
2. 
Review of clinical notes and treatment plans. 
3. 
Live observation of counseling sessions. 
4. 
Review and discussion of audiotapes or 
videotapes of counseling sessions. 
5. 
Cotherapy sessions. 
6. 
Group supervision with other counselors in 
which individual, family, or groups are 
reviewed or in which clinical concerns are 
shared and explored. 
One of the most helpful but time-intensive formats 
is where the counselor can be “seen in action.” 
This provides tremendous opportunities to identify 
personal or professional areas that need further 
attention. This is especially helpful to less 
experienced counselors. Once a counselor works 
through anxiety about being scrutinized, he or she 
usually finds this process helpful. 

Counselors should receive specific feedback 
regarding their counseling. This includes positive 
reinforcement for good work as well as critical 
feedback on areas of weakness. For example, a 
group counselor can benefit from feedback 
pointing out that he or she talks too much in the 
group sessions or tells patients how to cope with a 
recovery issue before eliciting their ideas on 
coping strategies. 

The use of adherence scales in some clinical 
research protocols is an excellent way of 
providing specific feedback on a particular 


treatment session. The counselor is rated on the 
performance of specific interventions as well as 
the quality of those interventions. The major 
drawback is that tapes of specific treatment 
sessions have to be reviewed in detail, a time-
consuming process. 

5. CLIENT-COUNSELOR RELATIONSHIP 
5.1 
What Is the Counselor’s Role? 
As evidenced by the list of counselor 
behaviors noted earlier, many roles are assumed in 
DDRC: educator, collaborator, adviser, advocate, 
and problemsolver. 

5.2 
Who Talks More? 
Generally, the patient talks the most during 
individual DDRC sessions. In PE groups, the 
counselor is usually very active in providing 
education to the group. However, patients are 
encouraged to ask questions, share personal 
experiences related to the group topic, and 
express feelings. 

5.3 
How Directive Is the Counselor? 
In DDRC, the counselor may be very 
directive and active with one patient and less 
directive and active with another. The approach 
must be individualized and take into account each 
patient’s strengths, abilities, and deficits. 
However, the counselor is generally more 
directive than in traditional mental health 
counseling, particularly in relation to continued 
drug use and relapse setups and in pointing out 
other self-defeating behavior patterns. 

5.4 
Therapeutic Alliance 
A good therapeutic alliance (TA) facilitates 
recovery and is based on the counselor’s ability to 
connect with the patient, respect differences, 
show empathy, use humor, and understand the 
inner world of the patient. Listening, providing 
information, being supportive and encouraging, 
and being up front and directive can help build the 
TA. 

A poor TA often shows in a patient’s missed 
appointments or failure to comply with treatment. 
Discussing common problems in recovery and 
acknowledging specific problems between the 
counselor and the patient can help improve a poor 
alliance. Calling patients who drop out of 
treatment early and inquiring as to whether they 
think a new treatment plan can help may also help 
correct a poor TA. Discussing specific cases in 
supervision can help the counselor identify causes 
of a poor TA and develop strategies to correct the 
problem. As a last resort, a case may be 
transferred to another counselor if the client-
counselor relationship is such that a TA cannot be 
formed. 

6. TARGET POPULATIONS 
6.1 
Clients Best Suited for This 
Counseling Approach 
The DDRC approach can be adapted for 
virtually any type of addiction, mental health 
disorder, or combination of dual disorders. 
However, it is best suited for mood, anxiety, 
schizophrenic, personality, adjustment, and other 
addictive disorders, in combination with alcohol or 
other drug addiction. 

6.2 
Clients Poorly Suited for This 
Counseling Approach 
Clients with mental retardation, organic brain 
syndromes, head injuries, and more severe forms 
of thought disorders are less suited for this 
counseling approach. 

7. ASSESSMENT 
The initial assessment involves a combination of 
the following: psychiatric evaluation, mental status 
exam, ASI, physical examination, laboratory work, 
and urinalysis. Patient and collateral interviews 
and review of previous records are part of the 
assessment process. The assessment process for 


inpatient treatment is more extensive and involved 
than assessment for outpatient care. 

An assessment covers the following areas: 
review of current problems, symptoms and 
reasons for referral, current and past psychiatric 
history, current and past drug use and abuse, 
history of treatment, mental status exam, medical 
history, family history, developmental history (e.g., 
development, school, work), current stressors, 
social support system, current and past suicidality, 
current and past aggressiveness or homicidality, 
and other areas based on the judgment of the 
evaluation team (e.g., relapse history, patterns of 
hospitalization). 

The drug abuse history should include specific 
drugs used (past and present), patterns of use 
(frequency, quantity, methods), context of use, and 
consequence of use (medical, psychiatric, family, 
legal, occupational, spiritual, financial). It should 
also include review of drug abuse or addiction 
symptoms (e.g., loss of control, obsession or 
preoccupation, tolerance changes, inability to 
abstain despite repeated attempts, withdrawal 
syndromes, continuation of use despite 
psychosocial problems, impairment caused by 
intoxications). Clinical interviews can be used as 
well as specific assessment instruments, such as 
the ASI, Drug Use Screening Inventory, Drug 
Abuse Screening Test, Milligan Alcoholism 
Screening Test, or other addiction-specific 
instruments. Regular or random urinalysis or 
breathalyzers can be used to monitor drug use, 
particularly in the early phases of recovery. 

Specific instruments may also be used for 
psychiatric disorders to obtain objective and 
subjective data. These may be administered by a 
professional (e.g., certain personality disorder 
interviews), or they may be completed by the 
patient at different points in time (e.g., Beck 
Depression or Anxiety Inventories, Zung 
Depression Inventory). These can also be used to 
gather baseline data and measure change in 
symptoms over time. 

Completing recovery workbook assignments or 
the drug abuse problem checklist (see Appendix 
for examples) is an additional way of assessing a 
patient’s perception of his or her problem areas 
related to drug use. The counselor can use these 
tools to identify specific areas for focus in 
individual DDRC sessions. 

8. SESSION FORMAT AND CONTENT 
8.1 Format for a Typical Session 
An individual DDRC session reviews 
addiction and mental health recovery issues. The 
time spent in a given session on addiction or 
mental health issues varies and depends on the 
specific issues and recovery status of a particular 
patient. For example, even if a depressed 
alcoholic patient were sober 9 months, the 
counselor may briefly inquire about any number of 
addiction recovery issues (e.g., cravings or close 
calls, actual episodes of use, involvement in self-
help group meetings, discussions with sponsors). 
Or, if an addicted patient’s depression were 
improved, the counselor would inquire about the 
typical symptoms this patient had prior to coming 
to treatment (e.g., mood, suicidality, energy). Any 
crisis issues would be attended to as well. 

The majority of time spent during the individual 
counseling session (unless a crisis takes up the 
session) focuses on the patient’s agenda. The 
patient is usually asked at the beginning of the 
session what concern or problem he or she wants 
to focus on in that day’s session. The problem or 
concern should be one that the patient has 
identified as an important part of his or her 
treatment plan. In relation to the problem or 
issues identified, the counselor helps the patient 
explore this to better understand and cope with it. 
Coping strategies are especially important since 
the session should be a purposeful one aimed at 
helping the patient work toward change. During 
the course of the DDRC session, any "live" 
material that is relevant to the patient’s dual 
disorders or recovery can be processed. For 


example, if the patient gives evidence of 
maladaptive thinking in the session that is 
contributing to anxiety or depressive symptoms 
(jumping to conclusions or focusing only on the 
negative), this can be pointed out and discussed in 
the context of the patient’s problems. 

The DDRC session ends with a review of what 
the patient will be doing between this and the next 
session relating to his or her recovery. It is helpful 
for the counselor to provide encouragement and 
positive feedback at the end of each session for 
the work that the patient accomplished and for the 
effort put forth. Reading, writing, or behavioral 
assignments may be given at the end of the 
session. The goal of these therapeutic 
assignments is to have the patient actively work 
on problems and issues between counseling 
sessions. 

8.2 
Several Typical Session Topics or 
Themes 
Medication visits and special consultations 
are held with the counselor and psychiatrist. 
These ensure integrated care, help prevent the 
patient from “splitting” the counselor and 
psychiatrist, and enhance ongoing team 
communication. These visits are usually brief and 
focus on medication issues or treatment 
compliance issues. The counselor gives the 
psychiatrist an update on treatment prior to the 
joint meeting. The counselor adds input during the 
session as needed. The psychiatrist and counselor 
can strategize after the meeting regarding 
therapeutic interventions. 

8.3 
Session Structure 
PE group sessions can easily be adapted to 
inpatient, residential, partial hospital, or outpatient 
settings. A specific PE group treatment 
curriculum can be developed for use in any 
treatment setting. PE group programs can vary in 
terms of number of sessions offered per week and 
total number of sessions offered during the 
treatment course. For example, patients in the 
author’s various inpatient dual disorders programs 

participate in up to five PE groups each week. 
Outpatients may attend weekly PE groups for up 
to several months. 

PE groups provide information on important 
recovery topics to patients and help them begin to 
explore different coping strategies to handle the 
various demands of recovery. It is important to 
try to balance the focus on problems and coping 
strategies so that patients can begin to be exposed 
to positive strategies that can help them deal with 
their issues and problems. 

PE group sessions are structured around a 
specific recovery issue or theme. The specific 
themes reviewed depend on the total number of 
sessions available for the patient. Each PE group 
is structured as follows (see Appendix for sample 
group sessions): 

1. 
Topic or recovery theme. 
2. 
Objectives or purpose of PE group session. 
3. 
Major points to review and methods of 
covering the material. 
4. 
PE group handouts to be read aloud, 
completed, and discussed in group, allowing 
members to relate personally to the PE topic. 
The group leader reviews the material 
interactively, so that patients can ask questions, 
share personal experiences related to the material 
covered, and provide help and support to one 
another. Outpatient and partial hospital PE group 
sessions usually last 1½ hours; inpatient PE group 
sessions usually last 1 hour. 

Prior to reviewing the PE group topic material in 
outpatient groups, the leader first takes time to 
discuss whether or not any patients have had 
setbacks, lapses or relapses, close calls, strong 
cravings to use drugs, or any other pressing issue 
since the last session. Some time is spent 


discussing these matters prior to reviewing the 
group curriculum. 

Specific topics or recovery themes explored in PE 
groups include:

 1. 
Understanding psychiatric illnesses (causes, 
symptoms, and treatment) and addiction 
(causes, symptoms, and treatment). 
2. 
Understanding relationships between drug 
use and psychiatric disorders. 
3. 
Denial of dual disorders and common 
roadblocks in recovery. 
4. 
Medical and psychiatric effects of drugs and 
addiction. 
5. 
Psychosocial effects of dual disorders. 
6. 
The recovery process for dual disorders. 
7. 
Medication education. 
8. 
Coping with cravings and desires to use 
alcohol or other drugs. 
9. 
Coping with anger, anxiety, and worry. 
10. 
Coping with boredom. 
11. 
Discovering ways to use leisure time. 
12. 
Coping with depression. 
13. 
Coping with guilt and shame. 
14. 
Family issues (e.g., impact of dual disorders, 
recovery resources, family treatment). 
15. 
Developing a sober recovery support system. 
16. 
Coping with pressures to get high or to stop 
taking psychiatric medications. 
17. 
Changing negative or maladaptive thinking. 
18. 
Spirituality in recovery. 
19. 
Joining AA/NA/CA, mental health, and dual 
recovery support groups and recovery clubs. 
20. 
Recovery prevention (warning signs, high-
risk factors). 
21. 
Followup inpatient care. 
22. 
Understanding and using psychotherapy and 
counseling. 
This material can also be modified and adapted for 
use in 90-minute weekly multiple family groups 
(MFGs) or for use in monthly, daily, or halfday PE 
workshops attended by patients and families or 
significant others (SOs). 

Any of the above themes as well as others may 
be explored in individual DDRC sessions. 

8.4 
Strategies for Dealing With Common 
Clinical Problems 
Lateness is discussed directly with the 
patient to determine the reasons for it, and 
strategies are discussed so the patient can better 
comply with the treatment schedule. Chronic 
patterns of lateness may be generalized as 
indicative of broader patterns of difficulty with 
responsibility or as part of a self-defeating pattern 
of behavior. 

Missed sessions are discussed with the patient to 
determine why and to work through any 
resistance the patient has. A patient who fails to 
show or who calls to cancel an appointment is 
usually called by the clinician or sent a friendly 
note in the mail offering another appointment or 
asking the patient to call so an appointment can be 
rescheduled. 

Interventions with patients who come to sessions 
under the influence are dealt with in a number of 
different ways depending on their condition. 


Detoxification and inpatient hospitalization may be 
arranged in severe cases involving potential 
withdrawal and florid psychiatric symptoms. In 
other cases, crisis intervention may be offered or 
the patient may be helped to make arrangements 
to go home and return for another appointment 
when not under the influence of chemicals. 
Generally, these situations are handled in the most 
appropriate clinical manner. Limits may be set 
without coming across as punitive or judgmental. 

Contracts noting a patient’s specific issues 
(lateness, missed sessions, failure to complete 
therapeutic assignments, coming to sessions under 
the influence of chemicals) may also be created. 

8.5 
Strategies for Dealing With Denial, 
Resistance, or Poor Motivation 
Treatment sessions deal with ambivalence of 
patients regarding ongoing participation in 
treatment. The counselor attempts to normalize 
and validate ambivalence or denial in the context 
of addiction or psychiatric illness. Education, 
support, the use of therapeutic assignments, 
sessions with the team to discuss symptoms and 
behaviors of the patient, and sessions involving 
collaterals such as family or SOs may be used to 
help deal with denial and resistance. Generally, 
any resistance is “grist for the therapeutic mill” 
and is explored in treatment sessions. 

Poor motivation is usually seen as a manifestation 
of illness, particularly with more severely addicted 
or psychiatrically impaired patients. Personality 
issues also greatly contribute to resistance and 
poor motivation. 

8.6 
Strategies for Dealing With Crises 
A very flexible approach is needed in dealing 
with crisis since dually diagnosed patients often 
experience exacerbations of illness. In more 
severe cases, voluntary or involuntary 
hospitalization may be sought to help stabilize a 
patient. Additional face-to-face sessions with any 
member(s) of the treatment team, including the 
case manager for persistently mentally ill patients, 

may also be held. In some instances, supportive 
sessions via telephone are conducted. All patients 
are given an emergency phone number that can 
be called 24 hours a day, 7 days a week, and all 
patients are instructed on how and when to use 
the psychiatric emergency room. 

8.7 
Counselor’s Response to Slips and 
Relapses 
The counselor typically approaches lapses or 
relapses as opportunities for the patient to learn 
about relapse precipitants or setups. All lapses 
and relapses to drug use are explored in an 
attempt to identify warning signs. Strategies are 
discussed to help the patient better prepare for 
recovery. Additional sessions or telephone 
contacts may be used to help the patient stabilize 
from some relapses. Inpatient detoxification or 
rehabilitation programs may be arranged in 
instances where the relapse is severe and cannot 
be interrupted with the help and support of 
counseling along with self-help programs (e.g., 
AA, NA, CA). 

Drug use relapses are processed in terms of their 
impact on psychiatric symptoms and recovery 
from dual disorders. If a patient is on medication, 
the possible interactions with alcohol or 
nonprescribed drugs are discussed. 

Psychiatric relapses are discussed in terms of 
warning signs and causes to help the patient 
determine what may have contributed to the 
relapse. Additional sessions with the counselor or 
other members of the treatment team may be 
provided to help the patient stabilize. Medication 
adjustments also may be made, depending on the 
symptoms experienced by the patient. 

When psychiatric symptoms are life threatening or 
cause significant impairment in functioning, an 
inpatient hospitalization may be arranged. 


9. 
ROLE OF SIGNIFICANT OTHERS IN 
TREATMENT 
Families are often adversely affected by a patient 
with dual disorders and have many questions and 
concerns regarding their ill member. Family 
members can have a significant impact on the 
patient and can be either an excellent source of 
support or an additional stress during the patient’s 
recovery. Counselors are encouraged to include 
families in assessment and treatment sessions. 
PE programs, MFGs, and individual family 
sessions may be used. Patients in need of family 
therapy may be referred to a social worker or 
therapist conversant with family therapy 
approaches if the DDRC counselor is not familiar 
with family therapy. Particular attention is paid to 
children of patients so that assessments can be 
arranged if a counselor feels that a psychiatric 
evaluation is warranted for a patient’s child. 

PE programs provide helpful information on dual 
disorders and recovery and encourage families to 
attend support groups for mental health disorders 
or addictive disorders (e.g., Nar-Anon or Al-
Anon). MFGs that include the patient and his or 
her family members and that combine open 
discussion with some focus on acquiring education 
can be offered on a weekly or monthly basis. 
Mutual help and support can be shared among 
members of different families. Individual family 
sessions can be used to focus on specific issues 
and problems of a particular family. 

The counselor also works with the patient on 
strategies to improve communication and 
relationships with family members even when they 
are not directly involved in treatment sessions or 
recovery group meetings. 

REFERENCES 

Catalano, R.; et al. Relapse in the addictions: 

Rates, determinants, and promising prevention 

strategies. 1988 Surgeon General’s Report 

on the Health Consequences of Smoking. 

Washington, DC: Office on Smoking and 
Health, 1988. 

Cloninger, R. Neurogenetic adaptive mechanisms 
in alcoholism. Science 1987. pp. 410-416. 

Daley, D.; Moss, H.; and Campbell, F. Dual 
Disorders: Counseling Clients with 
Chemical Dependency and Mental Illness. 
2d ed. Center City, MN: Hazelden, 1993. 

McLellan, A.T.; Luborsky, L.; Cacciola, J.; 
Griffith, J.; Evans, F.; Barr, H.L.; and 
O’Brien, C.P. New data from the Addiction 
Severity Index. Reliability and validity in three 
centers. J Nerv Ment Dis 173(7):412-423, 
1985. 

Meyer, R., ed. Psychopathology and Addictive 
Disorders. New York: Guilford Press, 1986. 


APPENDIX. A SAMPLE DUAL RECOVERY-PSYCHOEDUCATIONAL GROUP 


RELAPSE PREVENTION: AFTERCARE 
PLANNING/COPING WITH 
EMERGENCIES 

Objectives 

1. 
Teach patients the importance of having a 
followup aftercare plan to facilitate ongoing 
recovery. This plan should involve 
professional treatment and participation in 
self-help support programs (e.g., AA or NA) 
and mental health consumer groups. 
2. 
Teach patients that failure to comply with 
ongoing treatment increases the chances of 
chemical use or psychiatric relapse. 
3. 
Help patients identify potential benefits of 
continued involvement in treatment and 
recovery. 
4. 
Teach patients the importance of being 
prepared to handle emergencies (i.e., a return 
to chemical use or a return or worsening of 
psychiatric symptoms). 
Methods 

1. 
Use a lecture/discussion format. Write the 
major points on the board for reinforcement. 
2. 
State that studies and clinical experience show 
that patients who continue in treatment after 
discharge from the hospital do better than 
those who do not. Failure to comply often 
contributes to relapse. 
3. 
Stress the importance of taking medications 
even after symptoms are under control. 
4. 
Ask patients who have failed to comply with 
treatment in the past, and those who did, to 
state how this affected their addiction and 

psychiatric disorder. 

5. 
Have patients list potential benefits of 
complying with treatment. 
6. 
Ask patients what they could do if they felt 
their treatment plan was not working (i.e., 
instead of dropping out of treatment). 
7. 
Ask patients to list steps they could take if 
they lapsed or relapsed to chemical use or 
their psychiatric symptoms returned or 
worsened. 
SUGGESTED READINGS 

Alterman, A., ed. Substance Abuse and 
Psychopathology. New York: Plenum Press, 
1986. 

Co-Morbidity of Addictive and Psychiatric 
Disorders. Miller, N., and Stimmel, B., eds. 
Special edition of the J Addict Dis 12(3), 
1993. 

Daley, D., and Thase, M. Dual Disorders 
Recovery Counseling: A Biopsychosocial 
Treatment Model for Addiction and 
Psychiatric Illness. Independence, MO: 
Herald House/Independence Press, 1995. 

Evans, K., and Sullivan, J.M. Dual Diagnosis: 
Counseling the Mentally Ill Substance 
Abuser. New York: Guilford Press, 1991. 

Goodwin, D., and Jamison, K. Manic Depressive 
Illness. New York: Oxford University Press, 
1990. 

Minkoff, K., and Drake, R. Dual Diagnosis of 
Major Mental Illness and Substance 
Disorder. San Francisco, CA: Jossey-Bass, 
Inc., 1991. 

Montrose, K., and Daley, D. Celebrating Small 
Victories. Center City, MN: Hazelden, 1995. 

National Institute on Drug Abuse. Drug Abuse 
and Drug Abuse Research, Third Report to 


Congress. Rockville, MD: National Institute 

on Drug Abuse, 1991. pp. 61-83. 

O’Connell, D., ed. Managing the Dually 
Diagnosed Patient. New York: Haworth, 
1990. 

Pepper, B., and Ryglewicz, H. The Young Adult 
Chronic Patient. San Francisco, CA: Jossey-
Bass, Inc., 1982. 

Regier, D., et al. Co-morbidity of mental disorders 
with alcohol and other drug abuse: Results 
from the Epidemiologic Catchment Area 
Study. JAMA 264(19):2511-2518, 1990. 

SUGGESTED PATIENT AND FAMILY 
EDUCATIONAL MATERIALS 

Alcoholics Anonymous (Big Book). New York: 
AA World Services, Inc., 1976. 

Daley, D. Relapse Prevention Workbook (Dual 
Diagnosis). Center City, MN: Hazelden, 
1993. 

Daley, D. Dual Diagnosis Workbook: Recovery 
Strategies for Addiction and Mental Health 
Problems. Independence, MO: Herald 
House/Independence Press, 1994. 

Daley, D., and Montrose, K. Understanding 
Schizophrenia and Addiction. Center City, 
MN: Hazelden, 1993. 

Daley, D., and Roth, L. When Symptoms Return: 
Relapse and Psychiatric Illness. Holmes 
Beach, FL: Learning Publications, 1992. 

Daley, D., and Sinberg, J. A Family Guide to 
Coping with Dual Disorders. Center City, 
MN: Hazelden, 1994. 

The Dual Disorders Recovery Book. Center 
City, MN: Hazelden, 1993. 

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

Haskett, R., and Daley, D. Understanding 
Bipolar Disorder and Addiction. Center 
City, MN: Hazelden, 1994. 

Living Sober. I. Skokie, IL: Gerald T. Rogers 
Productions. Eight interactive recovery 

educational videos, clinician manual, and 

consumer workbook, 1994. 

Living Sober. II. Skokie, IL: Gerald T. Rogers 
Productions. Six interactive recovery 
educational videos, clinician manual, and 
consumer workbook, 1996. 

Narcotics Anonymous (Basic Text). Sun Valley, 
CA: NA World Services Office, 1993. 


Promise of Recovery. Skokie, IL: Gerald T. 
Rogers Productions. 1-800 227-9100. Eleven 
educational videos on mental health/dual 
diagnosis, clinician manual, and consumer 
workbook, 1995. 

Salloum, I., and Daley, D. Understanding 
Anxiety Disorders and Addiction. Center 
City, MN: Hazelden, 1993. 

Thase, M., and Daley, D. Understanding 
Depression and Addiction. Center City, MN: 
Hazelden, 1993. 

Weiss, R., and Daley, D. Understanding 
Personality Problems and Addiction. Center 
City, MN: Hazelden, 1994. 

AUTHOR 

Dennis C. Daley, M.S.W. 

Assistant Professor of Psychiatry 

and 

Program Director 

Center for Psychiatric and 
Chemical Dependency Services 

University of Pittsburgh Medical Center 

Western Psychiatric Institute and Clinic 

3811 O’Hara Street 

Pittsburgh, PA 15213 


The CENAPS® Model of Relapse Prevention Therapy 


(CMRPT®) 

Terence T. Gorski 

1. 
OVERVIEW, DESCRIPTION, AND 
RATIONALE 
1.1 
General Description of Approach 
The CENAPS® Model of Relapse 
Prevention Therapy (CMRPT®) is a 
comprehensive method for preventing chemically 
dependent clients from returning to alcohol and 
other drug use after initial treatment and for early 
intervention should chemical use occur. 

1.2 
Goals and Objectives of Approach 
The five primary goals of the CMRPT are to: 

1. 
Assess the global lifestyle patterns 
contributing to relapse by completing a 
comprehensive self-assessment of life, 
addiction, and relapse history. 
2. 
Construct a personalized list of relapse 
warning signs that lead the relapser from 
stable recovery back to chemical use. 
3. 
Develop warning sign management strategies 
for the critical warning signs. 
4. 
Develop a structured recovery program that 
will allow clients to identify and manage the 
critical warning signs as they occur. 
5. 
Develop a relapse early intervention plan that 
will provide the client and significant others 
with step-by-step instructions to interrupt 
alcohol and other drug use should it recur. 
1.3 Theoretical Rationale/Mechanism of 
Action 
The CMRPT is a clinical procedure that 
integrates the disease model of chemical addiction 
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 on outpatient delivery systems. The 
CMRPT consists of five primary components: 

1. 
Assessment. 
2. 
Warning sign identification. 
3. 
Warning sign management. 
4. 
Recovery planning. 
5. 
Relapse early intervention training. 
Cognitive, affective, and behavioral therapy 
principles are targeted to accomplish the specific 
goals of each CMRPT component. 

The CMRPT incorporates standard and structured 
group and individual therapy sessions and 
psychoeducational (PE) programs that focus 
primarily on these five primary goals. The 
treatment is holistic in nature and involves clients 
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 clients for 
treatment with this model. 

1.4 Agent of Change 
The primary agent of change is the 
completion of a structured clinical protocol in a 
process-oriented interaction among the client, the 


primary therapist or counselor, and members of 
the therapy groups. 

1.5 Conception of Drug Abuse/Addiction, 
Causative Factors 
The CMRPT has been under development 
since the early 1970s (Gorski 1989a). It 
integrates the fundamental principles of Alcoholics 
Anonymous (AA) with professional counseling 
and therapy to meet the needs of relapse-prone 
clients. 

The CMRPT can be described as the third wave 
of chemical addiction treatment. The first wave 
was the introduction of the 12 steps of AA. The 
second wave was the integration of AA with 
professional treatment into a model known as the 
Minnesota Model. The CMRPT, the third wave 
in chemical addiction treatment, integrates 
knowledge of chemical addiction into a 
biopsychosocial model and 12-step principles with 
advanced cognitive, affective, behavioral, and 
social therapy principles to produce a model for 
both primary recovery and relapse prevention 
(RP). 

The CMRPT is based on a biopsychosocial model, 
which states that chemical addiction is a primary 
disease or disorder resulting in abuse of and 
addiction to mood-altering chemicals. Long-term 
use of mood-altering chemicals causes brain 
dysfunction that disorganizes personality and 
causes social and occupational problems. 

The CMRPT is based on the belief that total 
abstinence plus personality and lifestyle change 
are essential for full recovery. People raised in 
dysfunctional families often develop self-defeating 
personality styles (AA calls them 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, which ends in 
physical or emotional collapse, suicide, or self-
medication with alcohol or other drugs. The 
CMRPT incorporates the roles of brain 
dysfunction, personality disorganization, social 
dysfunction, and family-of-origin problems to the 
problems of recovery and relapse. 


Brain dysfunction occurs during periods of 
intoxication, short-term withdrawal, and long-term 
withdrawal. Clients 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 to 18 months of sobriety, but 
there is a lifelong tendency of these symptoms to 
return during times of physical or psychosocial 
stress. 

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 to subside. 

Social dysfunction, which includes family, work, 
legal, and financial problems, emerges as a 
consequence of brain dysfunction and resultant 
personality disorganization. 

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. 

The relapse syndrome is an integral part of the 
addictive disease process. The disease is a 
double-edged sword with two cutting 
edges—drug-based symptoms that manifest 
themselves during active episodes of chemical use 
and sobriety-based symptoms that emerge during 
periods of abstinence. The sobriety-based 
symptoms create a tendency toward relapse that 
is part of the disease itself. Relapse is the process 
of becoming dysfunctional in sobriety because of 
sobriety-based symptoms that lead to renewed 
alcohol or other 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 other drug 
use or collapse occurs. RP therapy teaches 
clients to recognize and manage these warning 
signs and to interrupt the relapse progression early 
and return to positive progress in recovery. 

The CMRPT conceptualizes recovery as a 
developmental process that goes through six 
stages. The first stage is Transition, where clients 
recognize that they are experiencing alcohol- and 
other drug-related problems and need to pursue 
abstinence as a lifestyle goal so they can resolve 
these problems. The second stage is Stabilization, 
where clients recover from acute and postacute 
withdrawal and stabilize their psychosocial life 
crisis. The third stage is Early Recovery, where 
clients identify and learn how to replace addictive 
thoughts, feelings, and behaviors with sobriety-
centered thoughts, feelings, and behaviors. The 
fourth stage is Middle Recovery, where clients 
repair the lifestyle damage caused by the addiction 
and develop a balanced and healthy lifestyle. The 
fifth stage is Late Recovery, where clients resolve 
family-of-origin issues that impair the quality of 
recovery and act as long-term relapse triggers. 
The sixth stage is Maintenance, where clients 
continue a program of growth and development 


and maintain an active recovery program to 
ensure that they do not slip back into old addictive 
patterns. 

The CMRPT is based on a balanced 
biopsychosocial model that recognizes three 
primary psychological domains of functioning and 
three primary social domains of functioning. Each 
of these domains is considered equally important. 

The primary psychological domains are: 

1. Thinking. 
2. Feeling. 
3. Acting. 
The primary social domains are: 

1. Work. 
2. Friendship. 
3. Intimate relationships. 
The clinical goal is to help clients achieve 
competent functioning within each of these 
domains. 

Clients usually have a preference for one 
psychological domain and one social domain. 
These preferred domains become overdeveloped 
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. 

Imagery is viewed as a primary mediating function 
between thinking, feeling, and acting. The 
CMRPT makes extensive use of both guided 
imagery for mental rehearsal and spontaneous 
imagery for cognitive and emotional integration 
work. 

2. 
CONTRAST TO OTHER COUNSELING 
APPROACHES 
2.1 Most Similar Counseling Approaches 
The CMRPT is an applied cognitive-
behavioral therapy program. It is similar to 
Rational Emotive Therapy and Beck’s Cognitive 
Therapy Model. The primary difference is that 
the CMRPT applies cognitive-behavioral therapy 
principles directly to the problem, teaching 
chemically dependent clients how to maintain 
abstinence from alcohol and other drugs. 

The CMRPT heavily emphasizes affective 
therapy principles by focusing on the identification, 
appropriate labeling, and communication and 
resolution of feelings and emotions. The CMRPT 
integrates a cognitive and affective therapy model 
for understanding emotions by teaching clients 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 unrepress memories. The 
model relies heavily on guided and spontaneous 
imagery and sentence completion and repetition 
work designed to create corrective emotional 
experiences. 

This model is also similar to and has been heavily 
influenced by the Cognitive-Behavioral Relapse 
Prevention Model developed by Marlatt and 
Gordon (George 1989; Marlatt and Gordon 1985). 
The major difference is that the CMRPT 
integrates abstinence-based treatment and has 
greater compatibility with 12-step programs than 
the Marlatt and Gordon model. 

The CMRPT integrates well with a variety of 
cognitive, affective, behavioral, and social 
therapies. Its primary strength is that it allows 
clinicians from varying clinical backgrounds to 
apply their skills directly to RP. As a result, it is 
ideal for use by a multidisciplinary treatment team. 


2.2 Most Dissimilar Counseling 
Approaches 
The CMRPT is most dissimiliar to the 
following types of therapy: 

1. 
Therapies that view chemical addiction 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 clients who have 
exhibited physical and psychological addiction 
to alcohol and other drugs. 
3. 
Nondirective or client-centered approaches. 
4. 
Any form of therapy that isolates or 
exclusively focuses on any single domain of 
physical, psychological, or social functioning 
to the exclusion of the other domains of 
functioning. 
The CMRPT is very different from rigid cognitive 
therapy models, which believe the challenge of 
irrational thoughts will bring automatic emotional 
integration, or rigid affective therapy models, 
which believe that emotional catharsis work will 
automatically result in spontaneous cognitive and 
behavioral change. 

3. FORMAT 
The CMRPT uses a standard session format for 
problemsolving group therapy, individual therapy, 
and PE. 

3.1 Modalities of Treatment 
The CMRPT uses a standard session model 
of problemsolving group therapy consisting of 
group rules, group responsibilities, a standard 
group format, and a problemsolving group 
counseling format. 

3.1.1 Group Rules. The following rules are 
used as part of the problemsolving group process. 
1. 
Group members can say whatever they want, 
whenever they want. Silence is not a virtue 
in the group and in fact can be harmful to a 
group member’s recovery. 
2. 
Group members can refuse to answer any 
questions or participate in any activity other 
than basic group responsibilities. Group 
members cannot be forced to participate, but 
they have the right to express their feelings 
about any member’s silence or any member’s 
choice not to get involved. 
3. 
What is said and takes place in the group 
stays among the members. Only counselors 
can consult with fellow counselors to offer 
members better, more effective treatment. 
4. 
No swearing, putting down, fighting, or 
threats of violence are permitted. The threat 
of violence is considered as good as the act. 
5. 
No dating, romantic involvement, or sexual 
involvement among the members of the group 
is permitted, as these activities can sabotage 
the treatment of either one or both. If such 
involvement does begin, it should immediately 
be brought to the attention of a counselor. 
6. 
Anyone who decides to leave the group must 
inform the group (in person) prior to 
departure. 
7. 
Group members should be on time for the 
2-hour sessions and should not plan to leave 
before the session ends. No smoking, eating, 
or drinking is permitted. 
3.1.2 Group Responsibilities. Group members 
agree to fulfill the following basic group 
responsibilities: 
1. 
Offer their 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 on what was learned. 
4. 
Listen to other group members when they 
present problems. 
5. 
Ask questions to help clarify the problem or 
proposed solution. 
6. 
Offer feedback about the problem and the 
group member presenting the problem. 
7. 
When appropriate, share personal 
experiences with similar problems. 
8. 
Complete the closure exercise by reporting to 
the group what was learned in the session 
and what could be done differently as a result 
of what was learned. 
3.1.3 Problemsolving 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) are attended by the therapy team only. 
The other steps in the protocol take place during 
the actual group therapy session. 
1. 
Preparatory session. The session begins by 
reviewing clients’ treatment plans, goals, and 
current progress in implementing treatment 
interventions. Each client’s progress is 
reviewed, and an attempt is made to predict 
the assignments and problems that the client 
will present. 
2. 
Opening procedure (5 minutes). The 
counselor sets the climate for the group, 
establishes leadership, and helps clients warm 
up to the group process. 
3. 
Reactions to last session (15 minutes). Each 
group member describes his or her thoughts 
and feelings about the session and identifies 
three persons who stood out from that 
session and why they were remembered. 

4. 
Report on assignments (10 minutes). 
Exercises that clients are working on to 
identify and manage relapse warning signs or 
deal with other problems related to RP are 
shared or are completed during the session; 
other assignments are completed between 
sessions. 
Immediately following each member’s 
reactions, the counselor asks all group 
members who have received assignments to 
briefly answer the following questions: 

C 
What was the assignment and why was it 
assigned? 

C 
Was the assignment completed and, if not, 
what happened when it was tried? 

C 
What was learned by completing the 
assignment? 

C 
What feelings and emotions were 
experienced while working on the 
assignment? 

C 
Were there any issues that required 
additional work by the group? 

C 
Is there anything else that needs to be 
worked on in group today? 

5. 
Setting the agenda (3 minutes). After all 
assignments have been shared, the group 
counselor identifies those group members 
who want to work and announces their 
names and the order in which they will 
present. Those who do not present their 
work during this session are first on the 
agenda in the next one. It is best to plan on 
no more than three members presenting in 
any group session. 

6. 
Problemsolving group process (70 minutes). 
Clients present issues to the group, clarify 
them through group questioning, receive 
feedback from the group and (if appropriate) 
from the counselor, and develop assignments 
for continued progress. 
7. 
Closure exercise. When about 15 minutes 
remain in the group session, the counselor 
asks each member to share the most 
important thing he or she learned in group and 
what could be done differently as a result of 
what was learned. 
8. 
Debriefing session. This session reviews the 
client’s problems and progress, improves the 
group skills of the counselor, and helps 
prevent counselor burnout. It is especially 
helpful if this can be done with other 
counselors running similar groups. A brief 
review of each client is completed, 
outstanding group members and events are 
identified, progress and problems are 
discussed, and the personal feelings and 
reactions of the counselor are reviewed. 
3.2 Ideal Treatment Setting 
The ideal setting for the CMRPT is a primary 
outpatient program made up of a minimum of 
12 group sessions, 10 individual therapy sessions, 
and 6 PE sessions administered over a period of 
6 weeks. Clients with literacy problems, cognitive 
impairments, or mental and personality disorders 
usually require longer lengths of stay to complete 
the therapeutic objectives. Clients are detoxified 
in a variable-length-of-stay inpatient or residential 
facility. During detoxification, the client is 
stabilized, assessed, and motivated to continue 
with the CMRPT in a primary outpatient program. 
After completing the primary outpatient program, 
the client is transferred to 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 RP plan 
based on experiences in recovery. 

Brief readmission (3 to 10 days) for residential 
stabilization may be required should clients return 
to chemical use, develop severe warning signs that 
render them out of control and at risk, or put them 
at high risk of returning to chemical use. 

The CMRPT is well adapted for use with 
chemically dependent criminal offenders in the 
criminal justice system who have antisocial 
personality disorders. The CMRPT 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 12 weeks of incarceration, continued in a 
halfway setting for a period of 3 to 6 months, and 
then continued in a primary outpatient program for 
a minimum of 2 years. 

3.3 Duration of Treatment 
The CMRPT can be administered in a variety 
of settings over a variable number of sessions. 

3.3.1 Residential Rehabilitation Model. The 
CMRPT was originally used in 28-day residential 
programs and administered over a course of 20 
90-minute group therapy sessions, 12 individual 
therapy sessions, and 20 90-minute PE sessions. 
The protocol was supplemented by involvement in 
self-help groups. Clients were then transferred 
into a 90-day outpatient program consisting of 12 
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 12-step meetings and 6 RP 
support groups. 
3.3.2 Primary Outpatient Program. The 
CMRPT was later used in an intensive outpatient 
program consisting of 10 individual therapy 
sessions, 12 group therapy sessions, 6 PE groups, 
and attendance at 6 12-step meetings and 6 RP 
support groups. Clients were then transferred to a 
90-day warning-sign identification management 
group consisting of 12 group therapy sessions and 
6 individual therapy sessions and continued 

involvement in 12-step meetings and RP support 
groups. 

3.3.3 PE Programs. The CMRPT has been 
delivered as a PE program consisting of between 
8 and 24 education sessions ranging from 1½ to 
3 hours per session. Motivated clients with 
adequate reading and writing skills have been able 
to benefit from involvement in these programs. 
These PE programs are usually integrated with 
the residential or primary outpatient programs. 
3.4 Compatibility With Other Treatments 
The CMRPT is compatible with a variety of 
other treatments, including 12-step programs; 
family therapy; and a variety of cognitive, 
affective, and behavioral therapy models. 

The CMRPT works well with court diversion 
programs and employee assistance programs 
(EAPs). A special occupation RP protocol has 
been developed for use in conjunction with EAP 
referrals. This protocol focuses on identifying on-
the-job relapse warning signs and teaching EAP 
counselors and supervisors how to intervene on 
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. This model integrates the treatment of 
criminal thinking and antisocial personality 
disorders with chemical addiction recovery and 
RP methods. The protocol integrates a 
biopsychosocial model, a developmental model of 
recovery, and a relapse warning sign model 
designed for clients with antisocial personality 
disorders and other Cluster B personality 
disorders. This model is designed to be 
administered in long-term treatment as the client 
moves from incarceration to halfway house to 
intensive outpatient to ongoing outpatient settings 
over a period of 1 to 5 years. 

Specialty application of the CMRPT has been 
developed for clients with posttraumatic stress 

disorder (PTSD) resulting from child physical and 
sexual abuse (Trotter 1992). 

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 RP 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 relapse early 
intervention plan. 

3.5 Role of Self-Help Programs 
Because it is based on a disease model and 
abstinence-based treatment, the CMRPT is 
designed to be compatible with 12-step programs. 
A special interpretation of the 12 steps was 
developed to help clients relate 12-step program 
involvement to RP principles. 

Special self-help support groups called Relapse 
Prevention Support Groups (Gorski 1989b) were 
developed to encourage clients to continue in 
ongoing warning sign identification and 
management. 

4. 
COUNSELOR CHARACTERISTICS 
AND TRAINING 
The CMRPT is designed to be implemented at 
one of three levels: basic research prevention 
therapy (RPT), recovery-oriented RPT, and 
psychotherapy-oriented RPT. Different 
credentials are recommended for practice at each 
of these three levels. 

4.1 Educational Requirements 
Professionals with a variety of 
credentials—ranging from nondegreed certified 
addiction counselors to doctoral-level clinical 
psychologists—have been trained and successfully 


practice the CMRPT. The more training a 
counselor has in chemical addiction treatment and 
cognitive behavioral therapy, the more effective 
he or she is in utilizing the CMRPT. 

4.2 
Training, Credentials, and 
Experience Required 
Many counselors and therapists are able to 
use CMRPT techniques effectively after reading 
Staying Sober: A Guide for Relapse 
Prevention (Gorski and Miller 1986) and the 
Staying Sober Workbook (Gorski 1988), which 
outline the basic theories and clinical procedures. 
It is recommended that counselors become 
competency certified by completing a 6½-day 
training course and competency certification 
procedure. 

4.3 
Counselor’s Recovery Status 
Whether or not a counselor is in recovery is 
irrelevant to the delivery of the CMRPT. It is 
important that the counselor believe in abstinence-
based treatment, avoid the use of harsh 
psychonoxious confrontation, have good 
communication skills and well-developed helping 
characteristics, and be a role model for a 
functional and sober lifestyle. The capacity for 
empathy with the relapse-prone client is essential. 

4.4 
Ideal Personal Characteristics of 
Counselor 
Ideally, the RP counselor would be a 
recovering chemically dependent person with a 
past history of relapse who recovered using RP 
therapy methods, currently has over 5 years of 
uninterrupted sobriety, and has a master’s degree 
or above with advanced training in cognitive, 
affective, and behavioral therapy techniques. 

4.5 
Counselor’s Behaviors Prescribed 
RP counselors are trained to enter into a 
collaborative relationship with their clients. 
Supportive and directive approaches that avoid 
harsh, psychonoxious confrontation are required. 
A foundation of good basic counseling and therapy 

skills is required. Additional training in the 
procedures of the CMRPT is essential. 

4.6 
Counselor’s Behaviors Proscribed 
RP counselors are discouraged from 
becoming harshly confrontational. Confrontation 
is designed to be directive and supportive, with the 
counselor pointing out self-defeating ways of 
thinking and acting while advocating the basic 
integrity of the client. Any form of confrontation 
that disempowers the client or attacks the client’s 
core integrity as a human being is seen as 
inappropriate. 

The model is consistent with the professional code 
of ethics for counselors and therapists in that it 
proscribes personal relationships and romantic or 
sexual involvement with clients. 

4.7 
Recommended Supervision 
Supervision should be maintained on a 
regular basis and should combine both group 
supervision and individual supervision. Supervision 
should be problem focused and address issues of 
how to adapt the standard protocols to meet the 
individual needs of clients. 

Personal issues of the counselor only become a 
focus of the supervision when personal 
characteristics begin to interfere with the use of 
the effective use of the standard protocols. 
Should this occur, the supervisor generally 
addresses the immediate problem interfering with 
treatment and develops a plan with the counselor 
to modify his or her approach. Should problems 
continue, the counselor is referred to an EAP or a 
private therapist to resolve the private issues that 
are interfering with the therapy processes. 

5. CLIENT-COUNSELOR RELATIONSHIP 
5.1 What Is the Counselor’s Role? 
The counselor plays the role of educator, 
collaborator, and therapist. The counselor has a 
prescribed series of RP exercises to use that 


guide a client through the context of group therapy 
and individual therapy sessions and structured PE 
programs. The goal is to explain each procedure 
or exercises, assign appropriate homework 
exercises, and process the results of the 
homework in group and individual therapy 
sessions. The aim is to help clients recognize and 
manage relapse warning signs by facilitating 
insight, catharsis, and behavior change. 

5.2 Who Talks More? 
The client is expected to play an active role in 
the RP therapy process. The client 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. 

5.3 How Directive Is the Counselor? 
The counselor is very directive in establishing 
the agenda and maintaining compliance with 
standard clinical procedures. It is the counselor’s 
job to adapt the standard procedures to meet 
clients’ needs. The counselor expects clients to 
learn basic therapeutic skills and use them in the 
counseling process. Although the counselor 
directly enforces the use of a clinical procedure or 
process, he or she is careful to allow clients to 
provide the content for the therapy. Special care 
needs to be taken not to project problems on the 
clients that they do not have. 

6. TARGET POPULATIONS 
6.1 
Clients Best Suited for This 
Counseling Approach 
Clients who do well with the CMRPT have 
average or above-average conceptual skills and 
eighth grade or better reading and writing skills but 
no learning disabilities, severe cognitive 
impairments, active impulse control disorders, or 
other diagnosis that interferes with the ability to 
participate in a structured cognitive-behavioral 
therapy program. In addition, they have been 
detoxified. 

6.2 
Clients Poorly Suited for This 
Counseling Approach 
Clients who do not do well with the CMRPT 
are below average in conceptual level; have 
significant literacy problems; and have organic 
impairments, learning disabilities, or other mental 
disorders that interfere with their ability to respond 
to cognitive-behavioral therapy interventions. 

6.3 
Adaptation to Special Populations 
The CMRPT is adaptable to the needs of a 
variety of client populations. The techniques have 
been used successfully with cocaine addicts, 
adolescents, revolving-door detox clients, 
physically and sexually abused men and women, 
criminal justice system populations, and clients 
with dual diagnosis. The basic protocol, however, 
must be adapted to meet the needs of the 
specialty client group. 

7. ASSESSMENT 
Clients undergo a comprehensive screening 
interview to determine their appropriateness for 
the CMRPT. A comprehensive analysis of the 
client’s presenting problems, life and addiction 
history, and recovery and relapse history are then 
completed. A standard checklist of relapse 
warning signs is used to initiate warning sign 
identification and management. 


8. SESSION FORMAT AND CONTENT 
8.1 Format for a Typical Session 
The CMRPT uses problemsolving group 
therapy, individual therapy, and PE session 
formats. Clients are asked to make a commitment 
to a structured recovery program, to look at self-
help groups, and to consider holistic health 
approaches, including diet, exercise, and social 
and spiritual activities. 

8.2 Several Typical Session Topics or 
Themes 
Therapy is primarily directed toward the 
identification and management of relapse warning 
signs. This model consists of 37 structured 
exercises that have been developed over 20 years 
of clinical experience. These are presented in 
detail in The Staying Sober Workbook. The 
primary focus of all sessions is to guide clients in 
completing these exercises, which result in a 
personalized list of relapse warning signs (the 
unique personal problems that lead the client back 
to alcohol and other drug use) and warning sign 
management strategies (concrete situational and 
behavioral coping strategies for managing the 
warning signs without returning to chemical use). 

Clients are involved in a structured recovery 
program that provides holistic health maintenance 
for a healthy and sober lifestyle. Breaks in the 
recovery program are viewed as critical relapse 
warning signs, and immediate intervention is 
initiated when they become apparent. 

Other problems in recovery include situational life 
problems and symptoms of dual diagnosis, which 
are viewed as relapse warning signs. 
Management strategies are developed that provide 
direct treatment for these conditions and disorders 
as part of the RP therapy plan. 

Clients with dual disorders are treated in specialty 
RP programs with other relapse-prone chemically 
dependent clients with the same disorder, or they 


are referred for concurrent treatment in close 
coordination with RP therapy. 

8.3 Session Structure 
The CMRPT program is highly structured; 
compliance with the basic therapeutic structures is 
strongly emphasized and is a prerequisite for 
involvement. 

8.3.1 Group Therapy Format. Group therapy 
participants learn a standard problemsolving group 
process that guides problem resolution. The 
seven-step process is: 
1. 
Identify problems. Have clients ask 
questions to identify what is causing 
difficulty. What is the problem? 
2. 
Clarify problems. Clients are encouraged to 
be specific and complete. Is this the real 
problem, or is there a more fundamental 
problem? 
3. 
Identify alternatives. Have clients list 
alternatives on paper so they can readily see 
them. Then have the group come up with a 
list of at least five possible solutions. This 
gives clients more of a chance of choosing 
the best solution and gives them alternatives 
if their first choice does not work. What are 
some options for dealing with the 
problem? 
4. 
Project consequences. Have clients project 
implications of each alternative. What are 
the best, worst, and most likely outcomes 
that could be achieved by using each 
alternative solution? 
5. 
Make a decision. Have the group ask which 
option offers the best outcome and seems to 
have the best chance for success. Have the 
group then make a decision based on the 
alternatives. 
6. 
Take action. Once the group decides on a 
solution to the problem, they need to plan how 
they will carry it out. The plan should answer 
the question, What can be done about it? 

7. 
Follow up. Ask clients to carry out their 
plans and report back on their progress. 
8.3.2 Individual Therapy Format. The goal of 
individual therapy is to assist the client in 
identifying and clarifying problems and preparing 
to present them in group. A standard agenda is 
used. 
C Reactions to previous session. The counselor 
discusses the client’s reactions to the 
previous individual and group therapy 
sessions. 
C Sobriety check. The counselor asks the 
client if he or she has stayed clean and sober, 
experienced any cravings or urges to use 
alcohol or other drugs, and attended and 
participated in all scheduled recovery 
activities. 
C Clinical work. The issues that the client is 
currently working on are reviewed in depth. 
During this part of the session the counselor 
presents and identifies problems, clarifies the 
work to be done, and motivates the client to 
present issues in group. If intense cathartic 
work is required, this is usually done in 
individual sessions rather than in group 
therapy sessions. 
C Preparation for group. Each client rehearses 
how he or she will present issues to the 
group. The primary goal is to prepare and 
support each client in efficiently working on 
issues in group. Group is viewed as the 
primary or central treatment modality with 
individual therapy playing a supportive role. 

8.3.3 PE Group Format. A standard PE group 
format is used that is based on proven adult 
learning principles. 
Pretest. Participants are given a pretest to 
determine their knowledge level at the 
beginning of the sessions. 

C Lecture. A brief lecture is given describing 
the basic information for the class. 
C 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. 
C Posttest. Participants are given a posttest to 
see if they changed any of their answers as a 
result of the sessions. 
C Discussion. The counselor facilitates a group 
discussion and question-and-answer session 
to review the correct answers to the test. 

The lecture topics used relate to four general 
areas: 

1. 
Biopsychosocial disease process. The 
biopsychosocial symptoms of chemical 
addiction and other behavioral health 
disorders are explained. This topic is 
designed to help clients recognize and accept 
their chemical addiction and dual disorders 
and make a commitment to recovery. 
2. 
Developmental recovery process. The 
developmental stages of recovery from 
chemical addiction and other behavioral 
health disorders are explained. The 
educational exercises focus on helping clients 
identify their particular stage of recovery and 
develop appropriate recovery plans. The 
topic is designed to help clients recognize 
their current stage of recovery, develop an 
immediate recovery plan, and anticipate 
future long-term recovery needs. 
3. 
The relapse process. The common warning 
signs that precede relapse are explained, as 
are methods to identify and intervene on 
warning signs without using alcohol or other 
drugs. The process of relapse, early 
intervention, and rapid stabilization is also 

explained. This topic is designed to help 

clients recognize their personal relapse 

warning signs and to develop RP and early 

intervention plans. 

4. 
Accessing recovery resources. Recovery 
resources, such as ongoing counseling, 
12-step programs, Rational Recovery groups, 
and other sobriety support programs are 
explained. The goal is to teach clients how to 
build a structured long-term recovery 
program based on inexpensive and readily 
available community resources. 
The CENAPS Corporation publishes a 
comprehensive guide to recovery education called 

The Staying Sober Recovery Education 
Modules. This manual contains detailed 
education sessions following the processes 
described earlier for each vital educational area. 

8.4 Strategies for Dealing With Common 
Clinical Problems 
The CMRPT relies heavily on structured 
program procedures. The process is initiated with 
client contracting, and a commitment is secured 
for attendance, punctuality, and willingness to 
comply with client responsibilities and active 
participation within the session structures. Clients 
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 client’s ongoing therapy at 
risk and, hence, increase the risk of relapse. The 
following issues are promptly dealt with as critical 
issues. 

8.4.1 Lateness. Clients are expected to be on 
time for sessions. Following is the standard 
procedure for dealing with lateness. Prior to 
entering group, clients contract to be on time for 
all sessions. 
1. 
If clients arrive late within the first 
15 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. 
2. 
If clients are more than 15 minutes late for 
the first session, or if they are late for the 
second session, they are not allowed in group 
and must have an individual session with their 
therapist before being allowed back in group, 
where they must demonstrate that they have 
identified and resolved the issue(s) related to 
lateness. 
3. 
If clients are late on three or more occasions 
during any 12-week period, they are 
discharged from the group. 
Similar no-nonsense procedures are applied to 
individual therapy. Only extremely credible 
excuses are accepted for absence or tardiness 
and only if there is no pattern of absence or 
tardiness. 

8.4.2 Missed Sessions. Clients are expected 
to attend all therapy sessions. The only excuse 
for absence is extreme documented illness (with a 
physician’s note) and serious documented life 
crisis, such as a death in the family. All excused 
absences must be called in and be approved in 
advance by the counselor. Any pattern of three 
or more absences within any 12-week period is 
grounds for dismissal regardless of the reasons. 
8.4.3 Chemical Relapse and Intoxicated 
Clients. Intoxicated clients are not allowed to 
remain in group. If the group counselor suspects 
a client is intoxicated, the client is asked to verify 
it in group. If the client denies intoxication but his 
or her behavior gives reasonable cause to believe 
alcohol or other drugs have been used, the client is 
immediately given a breath test for alcohol and a 
urine drug screen. 

Appearing intoxicated for session is viewed as a 
chemical relapse. The client is immediately 
removed from group because he or she cannot 
benefit from therapy when under the influence of 
mood-altering drugs. An immediate screening 
appointment is established, and the client is 
admitted to a stabilization program at the 
appropriate level of care to deal with withdrawal. 

Procedures for dealing with chemical relapses 
follow. 

The counselor deals with relapse to alcohol and 
other drug use as a medical issue requiring 
stabilization and treats the client professionally. 
Anger at the client is viewed as a maladaptive 
countertransference response, which the 
counselor needs to resolve in clinical supervision. 

If a client refuses to follow recommendations for 
stabilization, he or she is terminated from 
treatment. If the client follows stabilization 
recommendations, he or she is evaluated at the 
end of stabilization and 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 RP strategies. 

In short, relapse is viewed as part of the disease 
and is dealt with nonjudgmentally and 
nonpunitively. The relapse is processed so it can 
become a learning experience for the client. 

8.5 Strategies for Dealing With Denial, 
Resistance, or Poor Motivation 
The CMRPT views resistance on a 
continuum from simple denial of chemical 
addiction 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 clients in severe and rigid denial are 
inappropriate candidates for RP therapy, they are 

referred to transitional counseling programs that 
are designed to deal with individuals who have 
high levels of denial and treatment resistance. 
When clients become treatment ready, they can 
reapply for admission to the RP program. 

8.6 Strategies for Dealing With Crises 
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 client is reassessed, the treatment 
plan is updated, and the client returns to working 
on standard RP tasks as outlined in the treatment 
plan. 

If possible, the crisis is stabilized in the context of 
the CMRPT. If the crisis is so severe that it 
interferes with the client’s ability to be involved, 
the client is transferred to another type or level of 
care to focus on the crisis stabilization. 

9. 
ROLE OF SIGNIFICANT OTHERS IN 
TREATMENT 
The CMRPT has a family treatment component 
that involves communication and intervention 
training around the developing warning signs, 
relapse, and early intervention, which allow the 
client and family members to have a concrete 
behavioral response should alcohol or other drug 
use recur. 

Family therapy is normally delivered in a “parallel 
model.” The client is involved in individual and 
group therapy for recovery from chemical 
addiction, and family members (especially the 
spouse or intimate partner) are encouraged to 
enter individual and group therapy for the 
treatment of coaddiction and other personal 
issues. Sessions are established to work with 
specific couples and family communication 
training and problemsolving. Special emphasis is 
placed on developing open communication around 


recovery goals, relapse warning signs for both 
chemical addiction and coaddiction, family 
warning sign identification and management skills, 
and family intervention planning in the event that 
alcohol or other drug use or acting out 
codependent behavior occur. 

The goal of family therapy is to remove the 
chemically dependent partner from the identified 
client role and create a family recovery focus in 
which each family member initiates a personal 
recovery program for chemical addiction or 
coaddiction. The family then 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 RP therapy. Many relapse-prone 
clients 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 clients can and 
do achieve long-term recovery with the CMRPT 
even though the family is not involved in 
treatment. 

REFERENCES 

George, W.H. Marlatt and Gordon’s Relapse 

Prevention Model: A cognitive-behavioral 

approach to understanding and preventing 

relapse. J Chem Depend Treat 2(2):153-169, 

1989. 

Gorski, T. The Staying Sober Workbook: A 
Serious Solution for the Problem of Relapse. 

Independence, MO: Herald House/ 

Independence Press, 1988. 
Gorski, T. How to Start Relapse Prevention 

Support Groups. Independence, MO: Herald 

House/Independence Press, 1989b. 

Gorski, T., and Miller, M. Staying Sober: A 
Guide for Relapse Prevention. 

Independence, MO: Herald 

House/Independence Press, 1986. 

Gorski, T.T. The CENAPS® Model of Relapse 
Prevention Planning. In: Daly, D.W. Relapse: 
Conceptual, Research, and Clinical 
Perspectives. Hayworth Press, 1989a. 
pp. 153-161 and J Chem Depend Treat (2)2, 
1989a. 

Marlatt, G.A., and Gordon, J.R., eds. Relapse 
Prevention: Maintenance Strategies in the 
Treatment of Addictive Behaviors. New 
York: Guilford Press, 1985. pp. 351-416. 

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

AUTHOR 

Terence T. Gorski 
President 
The CENAPS® Corporation 
18650 Dixie Highway 
Homewood, IL 60430 


The Living In Balance Counseling Approach 

Jeffrey A. Hoffman, Ben Jones, Barry D. Caudill, Dale W. Mayo, and Kathleen A. Mack 

1. 
OVERVIEW, DESCRIPTION, AND 
RATIONALE 
The Living In Balance (LIB) counseling approach 
is designed as a practical, instructional guide for 
conducting group-oriented treatment sessions for 
persons who abuse or are addicted to drugs. This 
approach has been fully described in Living in 
Balance: A Comprehensive Substance Abuse 
Treatment and Relapse Prevention Manual 

(Hoffman et al. 1995). The LIB program is both 
a psychoeducational (PE) and an experiential 
treatment model. It is designed so that clients can 
enter the program at any point in the cycle of 
sessions and continue in the program until all 
sessions are completed. The LIB manual is 
intended for use by professional counselors who 
have been trained in the provision of alcohol and 
other drug treatment and is appropriate for use in 
outpatient, inpatient, or residential treatment 
settings. 

The LIB manual was initially developed by a team 
of staff members and expert consultants 
associated with the Center for Drug Treatment 
and Research for a cocaine treatment research 
demonstration project funded by the National 
Institute on Drug Abuse (NIDA). Although it 
was originally designed specifically for a cocaine 
abuse population, it is holistic and generic in 
content and therefore applicable for the treatment 
of a wide range of drug abuse disorders, including 
polydrug abuse. 

1.1 General Description of Approach 
The LIB approach is specifically oriented for 
the group setting and utilizes techniques that draw 
from cognitive, behavioral, and experiential 
treatment approaches, with an emphasis on 
relapse prevention (RP). The LIB manual uses 

didactic education and instruction, group process 
interaction through role plays and discussion, daily 
relaxation and visualization exercises, 
informational handouts, videotapes, and group-
oriented recreational therapy exercises. Both 
counselors and clients may find the detailed 
organization and educational orientation of the LIB 
manual to be unfamiliar or uncomfortable at first, 
but over time both counselors and clients are likely 
to find that the manual provides a solid foundation 
for treatment that can be used in a flexible clinical 
context. 

There are 36 LIB sessions, each covering one 
specific topic. The major addiction-related topics 
include RP, drug education, and self-help 
education. Physical health issues addressed 
include nutrition, sexually transmitted diseases 
(STDs), HIV/AIDS, dental hygiene, and insomnia. 
Psychosocial topics include attitudes and beliefs, 
negative emotions, anger and communication, 
sexuality, spirituality, and the benefits of 
relationships. In addition, there are sessions on 
money management, education and vocational 
development, and loss and grieving. 

Each session contains a combination of PE, 
experiential (behavioral rehearsal and role 
playing), and group process and RP components. 
Throughout the LIB program, clients learn to 
monitor their own feelings and behavior and use 
relaxation and visualization techniques in the self-
assessment and goal-setting processes. 
Throughout the program clients learn to become 
actively involved in treatment—learning how to 
conduct self-assessments and actively implement 
coping and RP skills. One of the strongest 
emphases in the LIB program is to teach clients 
how to become their own relapse preventionists. 
This includes teaching them about the 


psychological and physiological components of 
addiction and recovery, and the various types of 
interventions and “life skills areas,” in which 
ongoing intervention is necessary. The LIB 
manual initially included recommendations for the 
use of several commercial videotapes; however, a 
set of nine brief videotapes was recently produced 
to accompany the LIB manual. 

1.2 Goals and Objectives of Approach 
1.2.1 Goals for Addiction Professionals. The 
LIB approach is designed to provide addiction 
professionals with a practical guide to conducting 
a series of 36 group treatment sessions for people 
who have drug use problems. The intent of the 
LIB program is to save addiction professionals 
time and expense by providing pre-prepared 
sessions, similar to a teacher’s lesson plans. 
In many treatment programs, the scope and 
quality of information and education provided to 
clients depend on the skills of the counselors 
working in the program at any given time. Thus, 
the scope of expertise may be limited, and the 
accuracy of the information may vary from 
counselor to counselor. In contrast, the 
developers of the LIB manual identified the 
primary issues that should be addressed in 
treatment and then created therapeutic sessions to 
address those issues. Thus, the LIB manual 
provides information about an extensive array of 
issues of importance to treatment and recovery. 
Also, the individual sessions of the LIB manual 
are based on current research in addictive 
behaviors and RP. 

1.2.2 Goals for Clients. Clients in treatment 
place significant emphasis on the following needs: 
1. 
Information about treatment and recovery. 
2. 
Skills to handle feelings and emotions. 
3. 
Information about preventing relapse. 
4. 
Practical living skills. 
5. 
Open confrontation when engaged in denial 
or other types of distorted thinking or 
behaviors. 
Thus, the goal of the PE approach of the LIB 
manual is to provide education, information, and 
experiences that will show people how to lead 
healthy and productive lives without using alcohol, 
cocaine, or other drugs. To achieve this goal, the 
LIB manual presents accurate information about 
drugs of abuse, RP, self-help programs, medical 
and physical health, emotional and social wellness, 
sexual and spiritual health, daily living skills, and 
vocational and educational development. 

The information is not presented as a long, boring 
lecture. Rather, each session is divided into 
manageable segments. Each of the 36 treatment 
sessions detailed in the manual allows for 
approximately 90 minutes of counselor 
interventions, presentations, or client training and 
includes sufficient time for questions. 

After each segment is a question-and-answer 
session that lets clients intensively interact with 
the counselor. 

During most sessions, there are written 
assignments that engage clients in an interactive 
exercise with the information. 

When appropriate, there are role-play exercises 
that encourage intense interaction and discussion 
among clients. 

Each session has one overriding goal with several 
specific client objectives. Clients are guided 
through a series of exercises that allow them to 
develop their own personal goals and objectives 
for each of the major life areas covered in the 
various treatment sessions. 

Using a combination of cognitive, relaxation, and 
visualization skills, clients are asked to identify, 


visualize, and take active steps toward their 
personal goals and objectives. A sample of a 
client self-assessment is provided in the Appendix 
at the end of the chapter. 

1.3 Theoretical Rationale/Mechanism of 
Action 
The basic rationale of the LIB model is that 
persons addicted to drugs develop a sense of 
imbalance in major areas of life functioning. 
Continuous drug use generally impairs a person’s 
physical health, emotional well-being, social 
relationships, work performance, and other major 
areas of functioning. Recovery involves regaining 
a reasonable balance in these critical areas. 
Balance in the major areas of life allows clients to 
free themselves from their addiction to drugs and 
provides protection against relapse to drug use. 
The concept of “living in balance” is essentially a 
broad, holistic approach to RP. 

RP is the single most important component of the 
LIB program. The first section of the program is 
devoted primarily to developing RP skills; RP 
sessions are scheduled strategically throughout the 
program. The understanding and skills that clients 
develop in these segments are meant to be used 
throughout the LIB program on a daily basis. The 
LIB program approach to RP is based in large 
part on a cognitive-behavioral model of RP 
developed by Marlatt and Gordon (1985). In this 
model, the former drug user confronts a high-risk 
situation for which he or she has no effective 
coping response. According to the model, 
high-risk situations can occur for many reasons, 
including social pressure to use drugs, negative 
emotions, and, less frequently, withdrawal 
symptoms and positive emotions. The lack of a 
coping response combined with positive 
expectancies for the initial effects of the drug in 
the situation greatly heighten the risk of a slip 
(Hall et al. 1991). 

Regarding relapse, the model suggests that “a 
person headed toward a slip makes numerous 
small decisions at the time which, although 

seemingly small and irrelevant at the time they are 
made, actually bring the individual closer to the 
brink of the slip. A chain of small decisions can 
lead, over time, to relapse” (Marlatt and Gordon 
1985). 

The biopsychosocial LIB approach to this 
patterning and slip chain is to rework it—to offer 
clients information about high-risk physical, social, 
and psychological situations and the potential 
impact of “small decisions”; to offer clients 
training in coping responses and stress reduction 
strategies; and to guide clients down alternative 
paths to pleasure and other life satisfactions. 

LIB RP helps clients: 

• 
Identify situations that trigger cravings. 
• 
Understand the chain of events, including 
“small decisions,” that lead from trigger to 
drug use. 
• 
Disrupt the chain at an early point. 
• 
Cope with triggers by using thought-stopping, 
visualization, and relaxation techniques. 
• 
Develop immediate alternatives to drug use. 
• 
Develop a long-term plan for full recovery. 
RP is viewed as a fundamental component of 
treatment and is consequently emphasized in the 
LIB manual by the use of repeated RP sessions. 
These sessions are intended to reinforce critical 
RP concepts and allow clients the opportunity to 
discuss and process difficult situations that they 
face in their daily lives that could easily lead to 
slips or full-blown relapse. Intensive use of 
visualization exercises is intended to strengthen 
RP skills and aid in forming and reinforcing 
personal goals. 

1.4 Agent of Change 

The agent of change in the LIB model is 
multidimensional, involving interaction among the 
group counselor, the client, and the other group 
members. Although a highly structured format is 
provided for conducting the group sessions, the 
counselor is encouraged to utilize his or her 
personal skills and experience to engage and 
involve the clients in treatment. In addition, group 
interaction is highly encouraged, and many of the 
activities such as role plays, discussions, and 
games are designed to facilitate group interaction 
and elicit emotional responses and social bonding. 
Intrapersonal techniques such as visualization, 
meditation, and even homework exercises are also 
extensively used, as they require personal 
responsibility and discipline on the part of the 
client for maximum benefit. 

1.5 Conception of Drug Abuse/Addiction, 
Causative Factors 
In the LIB approach, addiction is viewed as a 
biopsychosocial process that not only handicaps an 
individual’s functioning but also may destroy the 
cohesiveness of family and community 
relationships. Biopsychosocial processes refer to 
the inherited biological vulnerabilities, 
psychological predispositions, and pervasive social 
influences that converge to both form and 
perpetuate addictive behaviors. 

1.5.1 Biological Factors. Although related 
evidence is equivocal regarding biological 
contributions to addictive behaviors, it has been a 
common belief that some people are born with a 
genetic predisposition for developing an addiction 
when exposed to psychoactive drugs. Following 
chronic drug use, all people experience a severe 
biological (neurochemical) imbalance. Drug 
hunger, intoxication, and withdrawal are all 
manifestations of drug-induced imbalances of 
biologic homeostasis. 
1.5.2 Psychological Factors. Some people 
begin their drug use to diminish potent emotional 
and psychiatric symptoms. In turn, addiction 
causes a variety of psychological problems; drug 
use and withdrawal can cause numerous 
psychiatric symptoms. Even recovery can cause 
severe emotional turmoil. Importantly, addiction 
causes distortions in thinking such as denial, 
minimization, and projection. 

1.5.3 Social Factors. Various environmental 
factors increase the likelihood of exposure to 
specific drugs. For instance, certain drugs are 
more frequently used within certain cultures, and 
certain drugs are more easily found in certain 
geographic areas. For many people, drug use 
occurs in the context of a social network. In 
addition, addiction frequently causes severe 
disruptions in people’s social lives. Various social 
and environmental factors can also contribute to 
the triggering of drug hunger and relapse. 
Addiction is further viewed as a chronic, disabling 
condition in which relapses are common. Each 
client’s unique history and evolution of addiction 
must be evaluated at each of these levels, so that 
an effective treatment plan can be tailored to the 
client’s needs, strengths, and weaknesses. The 
more comprehensive the intervention, the more 
successful the outcome is likely to be. Because 
addiction affects multiple areas of clients’ lives, 
treatment efforts should address all major areas of 
living. 

The LIB program takes a nonjudgmental approach 
to addiction and lifestyle issues. In general, clients 
are viewed as people with a compulsive disorder 
that often overwhelms good intentions and 
willpower. Clients can be taught RP techniques to 
avoid a reemergence of the symptoms of 
addiction: compulsion, loss of control, continued 
use despite adverse consequences, and relapse. 

2. 
CONTRAST TO OTHER COUNSELING 
APPROACHES 
Addiction treatment using a PE group approach 
has been recommended to help clients learn basic 
life skills in order to confront daily problems and 


as a means of enhancing self-esteem (La Salvia 
1993). The LIB model is most similar to other PE 
programs that utilize a cognitive-behavioral 
approach with an emphasis on RP. LIB contrasts 
with these similar models, as well as the 12-step 
model originating from Alcoholics Anonymous 
(AA), which is not highly dissimilar to LIB but 
instead places an emphasis on different issues. 

2.1 
Most Similar Counseling Approaches 
The initial development of the LIB model 
drew some of its basic concepts from the 
Neurobehavioral Treatment Model (The Matrix 
Center 1989), particularly regarding the RP 
strategies. Some of the materials and handouts on 
RP were adapted from information in the Matrix 
Center’s manual. The primary difference 
between the Matrix neurobehavioral model and 
the LIB model is LIB’s emphasis on structured 
group counseling. The neurobehavioral model is a 
more flexible approach utilizing a combination of 
individual, family, and group therapies, with much 
less emphasis on group processing and 
experiences. 

The LIB model and the neurobehavioral model are 
also similar to other cognitive-behavioral 
approaches such as those developed for alcohol 
treatment as described in Treating Alcohol 
Dependence: A Coping Skills Training Guide 

(Monti et al. 1989). This approach also 
emphasizes client mastery of skills that will help 
them maintain abstinence from alcohol and other 
drugs. Clients are instructed to identify high-risk 
situations that may lead to relapse and analyze the 
external events, the internal cognitions, and the 
emotions that may precipitate relapse. Clients 
then develop plans and practice skills to cope with 
these situations, thoughts, and feelings, using 
various problemsolving, role-play, and homework 
exercises. 

Many of these basic RP concepts and techniques 
were based on the original work of Marlatt and 
Gordon (1985) and Gorski and Miller (1986). LIB 
uses these concepts in a simple and direct manner 

and expands on this approach to incorporate a 
comprehensive holistic view toward lifestyle 
change. 

2.2 
Most Dissimilar Counseling 
Approaches 
The 12-step addiction treatment model is 
most commonly used in addiction treatment 
programs. Its approach is grounded in the 
concept of addiction as a spiritual and medical 
disease, and its content is consistent with the 
12 steps of AA. In addition to abstinence, a major 
goal of this treatment approach is to foster each 
client’s commitment to participation in AA and 
Narcotics Anonymous (NA) self-help groups. 
Therapy sessions generally follow a similar format 
that includes symptoms inquiry, review and 
reinforcement for AA/NA participation, and 
introduction and explication of each session’s 
theme within the AA/NA philosophy (acceptance 
and surrender to the higher power, moral 
inventories, and sober living.) Material introduced 
during treatment sessions is often complemented 
by reading assignments from AA and NA 
literature. 

The LIB approach is not completely dissimilar to 
the 12-step approach and in fact incorporates 
many of its concepts and encourages participation 
in its self-help programs. LIB, however, places a 
much greater emphasis on learning and practicing 
critical RP skills and on strengthening major areas 
of a client’s life to reinforce protection against 
relapse. Like 12-step programs, LIB encourages 
spiritual exploration (finding a source of 
involvement greater than the self). But the 
primary focus remains on making informed 
decisions in everyday life that help the client 
regain balance and prevent relapse to drug use. 

3. FORMAT 
The LIB counseling approach is designed for 
group counseling in any type of drug treatment 
setting. It can be used as a primary modality over 


a period of 4 to 6 months, in combination with 
other treatment approaches (e.g., medical and 
psychosocial modalities), and for varying lengths 
of time. LIB incorporates a self-help approach 
and encourages participation in self-help programs 
that the client determines most suitable to his or 
her needs and personal philosophy. 

3.1 Modalities of Treatment 
The LIB program is designed for use in a 
group counseling format. Groups may range in 
size from 5 to 20, but a group numbering between 
12 and 15 has been found to provide a good 
balance between individual attention and group 
processing. LIB can be combined with other 
modalities such as individual and family 
psychotherapy and can be modified in accordance 
with the needs of specific treatment programs. 

3.2 Ideal Treatment Setting 
The LIB program can be used in drug abuse 
treatment settings as the core treatment or as an 
adjunct treatment strategy, depending on the 
clinical setting, level of care, and type of program. 
The LIB program can be used in all levels of care: 

• Inpatient or outpatient. 
• Intensive outpatient. 
• Partial hospitalization. 
• Continuing care and aftercare. 
• Evening or weekend programs. 
The LIB program can be used in a variety of 
program types: 

• Freestanding. 
• Hospital based. 
• Community based. 
• Corrections based. 
• Counseling centers. 
• Methadone treatment. 
• Therapeutic communities. 
• Halfway houses. 
• Therapists in private practice. 
The LIB program has been designed by a 
multidisciplinary team of healthcare professionals 
for use by trained addiction professionals. In 
many treatment programs, the LIB manual will be 
used primarily by addiction counselors and 
therapists. Some treatment programs may choose 
to have various healthcare professionals lead 
some of the group treatment sessions in their 
areas of expertise. Physicians may lead the 
sessions on STDs, nurses may lead the sessions 
on physical well-being, and nutritionists may lead 
the session on nutrition. 

3.3 Duration of Treatment 
The LIB manual is divided into 36 sessions. 
Each session lasts about 2 hours and is held 
3 days a week over a 12-week period (allowing 
for holidays and special events), or less frequently 
over a longer period of time. Specific sessions 
have been identified for different treatment 
settings, populations, and levels of care. The LIB 
program is designed so that clients can enter into 
the program at any session and continue the 
program until all of the intended sessions are 
completed. 

3.4 Compatibility With Other Treatments 
The LIB program can be used as the primary 
modality of treatment in an intensive outpatient 
program or in combination with other common 
modalities. Hoffman and colleagues (1994) found 
that when LIB groups were conducted 5 days a 
week, adding individual and family psychotherapy 
contributed little to increasing either the number of 
days or the number of sessions attended in 


outpatient treatment for cocaine abuse. However, 
when LIB groups were offered only twice a 
week, adding individual and family psychotherapy 
significantly increased the number of sessions 
attended. LIB has also been used effectively in 
methadone treatment programs, particularly during 
the early phases (Moolchan and Hoffman 1994). 
When used properly within the confines of a 
comprehensive treatment program, medication 
(including methadone) is viewed by the authors of 
the LIB concept as a useful adjunct in helping 
clients regain and maintain a life of balance and 
sobriety. LIB is also currently being used in 
residential treatment programs and specialized 
programs for drug-abusing women. 

3.5 
Role of Self-Help Programs 
The LIB program views the 12-step 
programs of AA, NA, and Cocaine Anonymous 
(CA) as important components in the treatment 
and recovery process for cocaine addiction. The 
LIB manual introduces clients to this and other 
self-help programs and encourages clients to 
attend self-help meetings during and following the 
formal treatment program. In addition, the manual 
embraces alternative recovery self-help groups 
and promotes spiritual awareness. The LIB 
manual also incorporates 12-step program 
references and examples throughout the text. 
Each client must find his or her own sources of 
support and fulfillment that extend beyond the 
limits of a treatment program and professional 
counseling. 

4. COUNSELOR CHARACTERISTICS 
AND TRAINING 
The effectiveness of any treatment model or 
counseling approach is determined by the 
personnel who use the model or deliver the 
program. The background, training, education, 
and experience of LIB counselors are critical to 
the effective use of this approach. Counselors 
who have more clinical training and related 
experience will be more capable of using various 

components of the model to effectively address 
the myriad issues that arise during a treatment 
session. 

4.1 
Educational Requirements 
The LIB model is designed to be used by 
anyone who has experience as a drug abuse 
counselor or who has other professional addictions 
training. Certification as an addictions counselor 
is also recommended but not required. Although 
an individual who has a high-school diploma would 
have adequate reading comprehension skills to use 
this model, it is recommended that the individual 
have an associate’s, bachelor’s, or master’s 
degree. This additional education and training 
would enhance an individual’s ability to fully 
understand the materials being presented and 
draw on his or her own experiences in developing 
certain concepts and ideas that are presented in 
the various sessions. 

Although the LIB manual is written in simple, 
easy-to-understand language, some of the 
concepts and exercises actually have very 
complex underpinnings. 

4.2 
Training, Credentials, and 
Experience Required 
Ideally, the individual using the LIB approach 
should have extensive training in the area of 
addictions. This level of training is encouraged 
because it provides a conceptual foundation and 
the skills requisite for any treatment modality. 
National certification as an addictions counselor is 
recommended; however, being a certified 
addictions counselor is not a requisite for using this 
counseling model. The effectiveness of the model 
is contingent on the counselor’s knowledge of the 
addictions field, his or her knowledge of various 
treatment techniques, and his or her experience in 
using those skills and techniques that are critical 
for working through the denial and resistance that 
are characteristic of a drug-using population. 

4.3 
Counselor’s Recovery Status 

The LIB counseling approach can be used by 
counselors who have had a recovery experience 
or who have never used drugs. A counselor’s 
recovery status is a complex issue that needs to 
be addressed in counselor training and supervision. 
It has been found that counselors who are 
recovering addicts can sometimes use their 
personal experiences to help illustrate certain 
points and that they have a greater sensitivity to 
some clients’ responses and concerns. However, 
it is also important that the recovering counselor 
have mastery of RP skills and practice them in his 
or her own life, because a counselor should serve 
as an example of a person who is leading a 
relatively balanced life. Counselors in recovery 
should use their own judgment, preferably in 
consultation with a supervisor, about when, how, 
and whether to reveal their own personal recovery 
experiences. This self-disclosure should be made 
only with a clear understanding of the potential 
benefits to the client. At no time should a 
counselor use the group sessions to discuss or 
resolve his or her own personal problems. 

4.4 
Ideal Personal Characteristics 
of Counselor 
While ideal counselor characteristics have 
not been clearly identified, some basic qualities 
that are useful in any counselor are sensitivity, a 
nonjudgmental attitude, and a genuine desire to 
help people struggle through some of the problems 
that led to their use of alcohol or other drugs. A 
counselor using the LIB model should be able to 
lead group discussions and provide basic 
instruction for those topics that require didactic 
presentation. Other personal characteristics that 
are helpful are openness, honesty, an ability to set 
appropriate limits, and a capacity for 
demonstrating caring while confronting behaviors 
that are inimical to the goals and objectives of the 
model. 

4.5 
Counselor’s Behaviors Prescribed 
The counselor should be skilled at 
confronting the client in denial. One of the major 
impediments to successful treatment is a client’s 

denial of his or her addiction. This denial 
expresses itself in many ways and many forms, 
from outright denial of having a drug problem to 
expressions of disinterest in the various topics and 
an unwillingness to discuss certain subjects. The 
counselor needs to be able to describe the 
behavior (e.g., avoiding certain topics, expressing 
denial), demonstrate the pattern of behavior as it 
appears, and relate the behavior to the defense 
mechanism of denial as it expresses itself in the 
course of treatment. 

In addition, the counselor must be ade