Relapse Is An Unpredictable Occurrence
Relapse is often quite predictable. The literature makes it clear that relapse is experienced by the great majority of people attempting to eliminate their addictions. Even those who obtain treatment are likely to relapse at some point. With or without treatment, those who develop stable and reliable strategies toward abstinence experience a much lower likelihood of relapse. Those who maintain high risk behaviors and unstructured lifestyles will often view relapse as unpredictable.
Relapsers often engage in high risk activities such as frequenting bars, going to parties where drugs are present, and keeping drug paraphernalia. They may have difficulty managing emotions such as depression and anger. Their environments may be disruptive. Many live in neighborhoods where access to drugs and alcohol is easy. Social conflict and psychosocial stressors are known to increase relapse risk. Lack of involvement in self-help or treatment activities can also interfere with recovery.
This myth is insidious because it can lead people to believe they are passive and helpless. Should relapse occur, they regard it as a random event instead of looking for causal patterns (which are usually present). Professionals in the field often mirror their patients' reaction because their own misconceptions about relapse leave them feeling inadequate. They become part of the problem by simply repeating earlier strategies or waiting for the patient to become "ready" for treatment.
Relapse Begins with the First Episode of Substance Abuse
Many recovering persons believe that abstinence is the only goal of recovery. As long as they remain drug free, they feel that they are making progress. Unfortunately, this approach confuses the end with the means. Abstinence, participation in A.A., treatment, or any other approach one cares to choose simply provides a way to improve the quality of life. As people proceed through recovery, they often develop improved communication skills, better relationships, and self-efficacy. These tools enhance a sense of belonging and meaning that prevents life from being perceived as burdensome and unsatisfying. In the absence of such coping mechanisms, addictive behavior may be regarded as the only option.
Another distinction is important here. A lapse can be considered a short-lived return to substance use that is followed by a reflection upon one's mistakes. Relapse would result from a lack of learning and a repetition of the pattern that led to the lapse.
Relapse Results from a Lack of Willpower
Willpower is a hallmark of the "moral weakness" explanation of addiction. This approach regards those who become addicted as morally or constitutionally weak. The solution is to become a more moral person by attaining religious beliefs or learning discipline.
The willpower approach focuses on mind over matter but in a simplistic way. It does not focus on avoiding difficult situations but on confronting them. Willpower is necessary only when a person is in a high risk situation. Obviously, there are times when such situations cannot be avoided, but those who need to rely on willpower repeatedly are probably taking unnecessary risks.
People Decide Consciously That They Want to Relapse
Addiction creates much automatic behavior. Addicts develop a set of behaviors that become second nature. These may include the rituals involved in using drugs, a daily routine that is built around substance use, or objects associated with substance use. Exposure to these situations may act as triggers for relapse. In responding to relapse triggers, relapsers often begin performing these behaviors in a reflexive manner.
As a result, relapsers make unconscious decisions that bring them closer to their drug of choice. Most relapsers are not aware of the triggers that set these behaviors into action and after relapsing may view the relapse as a random event. Others, however, may treat these individuals as if they planned a return to substance use. Because of this attitude there may be a tendency among abusers to hide the relapse for fear that others will interpret it as a devious act.
Relapse Occurs Only When the Original Drug of Choice Is Used
One of the most deceptive and common myths of relapse is that it occurs only with use of the originally abused drug. Many people in early recovery act as if there were separate recoveries for each drug that they take. Some even calculate "sobriety dates" independently for each drug.
An even more frequent example of this myth involves alcoholics who use (but do not abuse) marijuana. Counselors who attempt to convince these alcoholics that they should attempt to cease all drug use are met with such responses as "What's wrong with a joint now and then?" Such logic allows a continued reliance upon chemical problem-solving solutions and high-risk situations. Substitution of alternative drugs is well known among drug users and serves only to perpetuate the cycle of relapse.
Substitution is not limited to substance use; it can include other compulsive behaviors. Compulsive gambling, eating, working, and even spending have been noted in alcoholics and drug addicts prior to relapse. These behaviors often represent an escape from direct communication and development of self-knowledge.
Relapsers Enter Recovery Only When They "Hit Bottom"
The "hitting bottom" concept is a central theme in 12 Step programs. It assumes that pain has a linear relationship with success: the more pain, the better. However, many addicts are in a high degree of pain at the outset and some use substances to medicate this pain. An increase in pain often immobilizes them to the point of hopelessness.
This observation has implications for interventions such as confrontation, which tend to create resistance in patients already in a high state of pain. Such treatment is much more suitable for "low pain" patients as it can potentially increase pain to an optimal level - a possible explanation for the mixed results obtained with confrontation.
Relapse Means Failure
The myth that relapse means failure is tied to the notion that an attempt at recovery can be measured at a single point in time. Rather than focusing on the recovering individual's balance of strengths and weaknesses, attention is paid only to the actual substance usage. This focus prevents a mobilization of strengths when they are needed most. Instead, relapse should be regarded as a mistake that has arisen due to a lack of knowledge or skills. The relapser has probably engaged in high-risk activities or built an incomplete recovery plan. Reviewing these mistakes provides a positive framework for change rather than a negative and judgmental atmosphere. When a relapse is treated this way, if there is another in the future, the recovering addict will be much more likely to discuss it openly.
Relapse Negates Any Growth Made Up to That Point
Because of the focus on abstinence, there is a misconception that one needs to "start from square one" after the relapse. Those who have been counting their days of sobriety must begin their count again. However, it is not as if the addict has forgotten all previous knowledge when a relapse occurs. Most relapsers retain much learned information that they can use in the future. Recovery is a stepwise learning process in which there may be downward steps, but which, one hopes, leads to an overall upward trend.
The myth that a relapse negates all growth is dangerous because relapsers can easily become discouraged. They may assume that they have to repeat their earlier learning, a step which could increase their guilt and embarrassment. Anyone who has worked with relapsers knows that shame and embarrassment can lead to avoidance and extend the relapse episode. Such individuals do not have to relearn old material; they need to focus on unattended areas in their recoveries. Stepwise learning through correction of mistakes can bring relapsers back into recovery much sooner.
Relapse Means That the Relapser Is Not Motivated
When there is a negative outcome to treatment, often the explanation is that the relapser is not motivated. while there are certainly many addicts who make insufficient efforts toward recovery, clinicians need to be careful not to confuse motivation with compliance. The patient may truly want to stop abusing drugs or alcohol but may have difficulty complying because of cognitive deficits, inadequate social support, or past negative treatment experiences. If clinicians assist the patient in breaking these barriers rather than expecting a ready-made package of motivation when the patient enters treatment, then outcome can certainly be enhanced.
In addition, the patient may lack knowledge of important high-risk factors that he or she needs to address. Educational efforts can help the patient develop the understanding necessary for a positive outcome. Most important, the clinician needs to assess the roots of insufficient motivation instead of relegating the patient to the "unmotivated" category.
All Recovering Individuals Have the Same Relapse Potential
One of the advantages of the traditional disease model is that it assumes an ever-present danger of relapse. While this notion may keep recovering people vigilant, one should not assume that everyone has the same level of risk. Risk is dependent on a variety of biological, psychological, and social factors that differ among recovering individuals. Risk is a function of behavior; to suggest that there is no way to control it is erroneous. Assumption of a passive stance can only reduce vigilance to warning signs and precipitate a relapse.
Relapse Involves Use of Alcohol and Drugs Only
The belief that relapse involves only alcohol and drug use is an open invitation to replace substance abuse with compulsive behaviors such as eating disorders, workaholism, compulsive gambling and spending, orexcessive reliance on sex and relationships.
Because primary attention is paid to substance use, many recovering individuals assume that such replacements are acceptable. However, the consequences of these addictions can be as detrimental as the original addictions. One recovering heroin addict remained abstinent for 36 months but began abusing his credit cards during that time. He ran up a bill of $29,000 and eventually relapsed. One recovering alcoholic worked 100-hour weeks until he became extremely fatigued and turned to alcohol. In both cases, their peers thought that these individuals were adapting well to recovery and had no significant problems.
Withdrawal Is Complete Within Several Days
Although the acute effects of drugs last for a relatively short period of time, neuropsychological research strongly indicates that there are longer lasting cognitive dysfunctions that can extend for months or even years. This phenomenon is usually referred to a post acute withdrawal. Difficulties such as memory disturbance, problems with abstract reasoning, sleep interruption, emotional imbalance, and sensitivity to stress are often present.
Although the phenomenology of this syndrome is highly variable, it is important to recognize the confusion caused by its symptoms in early recovery. Many people in early recovery mistakenly assume that their clarity of thinking will return to normal shortly after withdrawal and become upset then these symptoms are still present months later. They regard the symptoms as representative of recovery rather than as consequences of addiction. Some become frustrated and return to alcohol or drugs. As a result, it is critical that those in early recovery be informed of cognitive changes that may occur.
Relapsers Should Receive the Same Treatment as Other Substance Abusers
For many years, the typical response to relapse was to recycle the relapser through the same treatment that he or she received prior to the relapse. Treatment professionals assumed that the relapser was not motivated or had not "hit bottom," so a repetition of treatment would provide the appropriate refresher. They thought that reminders to attend A.A., seek sponsorship, and "ask for help" would suffice. Ironically, there tended to be little discussion of the circumstances surrounding the relapse and even less formal assessment. As a result, addicts did not gain ay insight into important cognitive and behavioral tendencies and often drifted back into further relapses.
Professionals must recognize that ignorance of such vital information is counterproductive; they realize that relapses can be viewed as mistakes that provide clues about the weakness in a person's recovery. Correction of these weaknesses constitutes the stepwise learning needed for long-term recovery.
Relapse Is Caused by Negative Events in a Person's Life
While it is wrong to consider relapse a random event, it is equally misguided to consider that it is caused by particular negative events. It is not the actual event but the perception of the event that is crucial. Blaming relapse on situations can often enhance denial, as many addicts make excuses for their behavior. I was once told by a relapser that he broke his sobriety when he became angry that his garage opener did not work. Another person relapsed when he became angry at a slow-moving "express" line at the grocery store. On the other hand, I have heard of people who maintain their recoveries in the face of serious emotional traumas such as family deaths, accidents, and personal misfortune. There is not enough attention paid to those who are resilient in dealing with such stress.
In addition, many alcoholics and addicts report relapse after positive developments such as promotions at work, commendation from friends and relatives, or financial success. some individuals become complacent and drift away from methods that assisted them in developing sobriety in the first place.
To avoid this pitfall it is important for the recovering person not to overestimate his or her progress.
Treatment Professionals Have No Ability to Predict Relapse
The myth that relapses cannot be predicted by clinicians encourages a pessimistic attitude toward treatment for professional and patient alike. As stated earlier, the belief that relapse is random can be quite counterproductive in recovery. In fact, patients provide many clues about their relapse potential while in treatment. In addition, much is known about biological, psychological, and social factors that lead to relapse. These factors appear to operate at some level in all addictions. A comprehensive and systematic approach to assessment will provide a good estimate of relapse potential.
The relapse syndrome is a degenerative process that creates a progression of symptoms within the patient who has previously experienced remission from alcoholism or drug dependence. The syndrome causes the patient to become dysfunctional or incapacitated while sober. It manifests itself in a progressive pattern of behavior and terminates in alcohol/drug use or related debilitating conditions.
FIFTEEN MYTHS OF RELAPSE AND RECOVERY
Relapse Is An Unpredictable Occurrence
Relapse is often quite predictable. The literature makes it clear that relapse is experienced by the great majority of people attempting to eliminate their addictions. Even those who obtain treatment are likely to relapse at some point. With or without treatment, those who develop stable and reliable strategies toward abstinence experience a much lower likelihood of relapse. Those who maintain high risk behaviors and unstructured lifestyles will often view relapse as unpredictable.
Relapsers often engage in high risk activities such as frequenting bars, going to parties where drugs are present, and keeping drug paraphernalia. They may have difficulty managing emotions such as depression and anger. Their environments may be disruptive. Many live in neighborhoods where access to drugs and alcohol is easy. Social conflict and psychosocial stressors are known to increase relapse risk. Lack of involvement in self-help or treatment activities can also interfere with recovery.
This myth is insidious because it can lead people to believe they are passive and helpless. Should relapse occur, they regard it as a random event instead of looking for causal patterns (which are usually present). Professionals in the field often mirror their patients' reaction because their own misconceptions about relapse leave them feeling inadequate. They become part of the problem by simply repeating earlier strategies or waiting for the patient to become "ready" for treatment.
Relapse Begins with the First Episode of Substance Abuse
Many recovering persons believe that abstinence is the only goal of recovery. As long as they remain drug free, they feel that they are making progress. Unfortunately, this approach confuses the end with the means. Abstinence, participation in A.A., treatment, or any other approach one cares to choose simply provides a way to improve the quality of life. As people proceed through recovery, they often develop improved communication skills, better relationships, and self-efficacy. These tools enhance a sense of belonging and meaning that prevents life from being perceived as burdensome and unsatisfying. In the absence of such coping mechanisms, addictive behavior may be regarded as the only option.
Another distinction is important here. A lapse can be considered a short-lived return to substance use that is followed by a reflection upon one's mistakes. Relapse would result from a lack of learning and a repetition of the pattern that led to the lapse.
Relapse Results from a Lack of Willpower
Willpower is a hallmark of the "moral weakness" explanation of addiction. This approach regards those who become addicted as morally or constitutionally weak. The solution is to become a more moral person by attaining religious beliefs or learning discipline.
The willpower approach focuses on mind over matter but in a simplistic way. It does not focus on avoiding difficult situations but on confronting them. Willpower is necessary only when a person is in a high risk situation. Obviously, there are times when such situations cannot be avoided, but those who need to rely on willpower repeatedly are probably taking unnecessary risks.
People Decide Consciously That They Want to Relapse
Addiction creates much automatic behavior. Addicts develop a set of behaviors that become second nature. These may include the rituals involved in using drugs, a daily routine that is built around substance use, or objects associated with substance use. Exposure to these situations may act as triggers for relapse. In responding to relapse triggers, relapsers often begin performing these behaviors in a reflexive manner.
As a result, relapsers make unconscious decisions that bring them closer to their drug of choice. Most relapsers are not aware of the triggers that set these behaviors into action and after relapsing may view the relapse as a random event. Others, however, may treat these individuals as if they planned a return to substance use. Because of this attitude there may be a tendency among abusers to hide the relapse for fear that others will interpret it as a devious act.
Relapse Occurs Only When the Original Drug of Choice Is Used
One of the most deceptive and common myths of relapse is that it occurs only with use of the originally abused drug. Many people in early recovery act as if there were separate recoveries for each drug that they take. Some even calculate "sobriety dates" independently for each drug.
An even more frequent example of this myth involves alcoholics who use (but do not abuse) marijuana. Counselors who attempt to convince these alcoholics that they should attempt to cease all drug use are met with such responses as "What's wrong with a joint now and then?" Such logic allows a continued reliance upon chemical problem-solving solutions and high-risk situations. Substitution of alternative drugs is well known among drug users and serves only to perpetuate the cycle of relapse.
Substitution is not limited to substance use; it can include other compulsive behaviors. Compulsive gambling, eating, working, and even spending have been noted in alcoholics and drug addicts prior to relapse. These behaviors often represent an escape from direct communication and development of self-knowledge.
Relapsers Enter Recovery Only When They "Hit Bottom"
The "hitting bottom" concept is a central theme in 12 Step programs. It assumes that pain has a linear relationship with success: the more pain, the better. However, many addicts are in a high degree of pain at the outset and some use substances to medicate this pain. An increase in pain often immobilizes them to the point of hopelessness.
This observation has implications for interventions such as confrontation, which tend to create resistance in patients already in a high state of pain. Such treatment is much more suitable for "low pain" patients as it can potentially increase pain to an optimal level - a possible explanation for the mixed results obtained with confrontation.
Relapse Means Failure
The myth that relapse means failure is tied to the notion that an attempt at recovery can be measured at a single point in time. Rather than focusing on the recovering individual's balance of strengths and weaknesses, attention is paid only to the actual substance usage. This focus prevents a mobilization of strengths when they are needed most. Instead, relapse should be regarded as a mistake that has arisen due to a lack of knowledge or skills. The relapser has probably engaged in high-risk activities or built an incomplete recovery plan. Reviewing these mistakes provides a positive framework for change rather than a negative and judgmental atmosphere. When a relapse is treated this way, if there is another in the future, the recovering addict will be much more likely to discuss it openly.
Relapse Negates Any Growth Made Up to That Point
Because of the focus on abstinence, there is a misconception that one needs to "start from square one" after the relapse. Those who have been counting their days of sobriety must begin their count again. However, it is not as if the addict has forgotten all previous knowledge when a relapse occurs. Most relapsers retain much learned information that they can use in the future. Recovery is a stepwise learning process in which there may be downward steps, but which, one hopes, leads to an overall upward trend.
The myth that a relapse negates all growth is dangerous because relapsers can easily become discouraged. They may assume that they have to repeat their earlier learning, a step which could increase their guilt and embarrassment. Anyone who has worked with relapsers knows that shame and embarrassment can lead to avoidance and extend the relapse episode. Such individuals do not have to relearn old material; they need to focus on unattended areas in their recoveries. Stepwise learning through correction of mistakes can bring relapsers back into recovery much sooner.
Relapse Means That the Relapser Is Not Motivated
When there is a negative outcome to treatment, often the explanation is that the relapser is not motivated. while there are certainly many addicts who make insufficient efforts toward recovery, clinicians need to be careful not to confuse motivation with compliance. The patient may truly want to stop abusing drugs or alcohol but may have difficulty complying because of cognitive deficits, inadequate social support, or past negative treatment experiences. If clinicians assist the patient in breaking these barriers rather than expecting a ready-made package of motivation when the patient enters treatment, then outcome can certainly be enhanced.
In addition, the patient may lack knowledge of important high-risk factors that he or she needs to address. Educational efforts can help the patient develop the understanding necessary for a positive outcome. Most important, the clinician needs to assess the roots of insufficient motivation instead of relegating the patient to the "unmotivated" category.
All Recovering Individuals Have the Same Relapse Potential
One of the advantages of the traditional disease model is that it assumes an ever-present danger of relapse. While this notion may keep recovering people vigilant, one should not assume that everyone has the same level of risk. Risk is dependent on a variety of biological, psychological, and social factors that differ among recovering individuals. Risk is a function of behavior; to suggest that there is no way to control it is erroneous. Assumption of a passive stance can only reduce vigilance to warning signs and precipitate a relapse.
Relapse Involves Use of Alcohol and Drugs Only
The belief that relapse involves only alcohol and drug use is an open invitation to replace substance abuse with compulsive behaviors such as eating disorders, workaholism, compulsive gambling and spending, orexcessive reliance on sex and relationships.
Because primary attention is paid to substance use, many recovering individuals assume that such replacements are acceptable. However, the consequences of these addictions can be as detrimental as the original addictions. One recovering heroin addict remained abstinent for 36 months but began abusing his credit cards during that time. He ran up a bill of $29,000 and eventually relapsed. One recovering alcoholic worked 100-hour weeks until he became extremely fatigued and turned to alcohol. In both cases, their peers thought that these individuals were adapting well to recovery and had no significant problems.
Withdrawal Is Complete Within Several Days
Although the acute effects of drugs last for a relatively short period of time, neuropsychological research strongly indicates that there are longer lasting cognitive dysfunctions that can extend for months or even years. This phenomenon is usually referred to a post acute withdrawal. Difficulties such as memory disturbance, problems with abstract reasoning, sleep interruption, emotional imbalance, and sensitivity to stress are often present.
Although the phenomenology of this syndrome is highly variable, it is important to recognize the confusion caused by its symptoms in early recovery. Many people in early recovery mistakenly assume that their clarity of thinking will return to normal shortly after withdrawal and become upset then these symptoms are still present months later. They regard the symptoms as representative of recovery rather than as consequences of addiction. Some become frustrated and return to alcohol or drugs. As a result, it is critical that those in early recovery be informed of cognitive changes that may occur.
Relapsers Should Receive the Same Treatment as Other Substance Abusers
For many years, the typical response to relapse was to recycle the relapser through the same treatment that he or she received prior to the relapse. Treatment professionals assumed that the relapser was not motivated or had not "hit bottom," so a repetition of treatment would provide the appropriate refresher. They thought that reminders to attend A.A., seek sponsorship, and "ask for help" would suffice. Ironically, there tended to be little discussion of the circumstances surrounding the relapse and even less formal assessment. As a result, addicts did not gain ay insight into important cognitive and behavioral tendencies and often drifted back into further relapses.
Professionals must recognize that ignorance of such vital information is counterproductive; they realize that relapses can be viewed as mistakes that provide clues about the weakness in a person's recovery. Correction of these weaknesses constitutes the stepwise learning needed for long-term recovery.
Relapse Is Caused by Negative Events in a Person's Life
While it is wrong to consider relapse a random event, it is equally misguided to consider that it is caused by particular negative events. It is not the actual event but the perception of the event that is crucial. Blaming relapse on situations can often enhance denial, as many addicts make excuses for their behavior. I was once told by a relapser that he broke his sobriety when he became angry that his garage opener did not work. Another person relapsed when he became angry at a slow-moving "express" line at the grocery store. On the other hand, I have heard of people who maintain their recoveries in the face of serious emotional traumas such as family deaths, accidents, and personal misfortune. There is not enough attention paid to those who are resilient in dealing with such stress.
In addition, many alcoholics and addicts report relapse after positive developments such as promotions at work, commendation from friends and relatives, or financial success. some individuals become complacent and drift away from methods that assisted them in developing sobriety in the first place.
To avoid this pitfall it is important for the recovering person not to overestimate his or her progress.
Treatment Professionals Have No Ability to Predict Relapse
The myth that relapses cannot be predicted by clinicians encourages a pessimistic attitude toward treatment for professional and patient alike. As stated earlier, the belief that relapse is random can be quite counterproductive in recovery. In fact, patients provide many clues about their relapse potential while in treatment. In addition, much is known about biological, psychological, and social factors that lead to relapse. These factors appear to operate at some level in all addictions. A comprehensive and systematic approach to assessment will provide a good estimate of relapse potential.
The relapse syndrome is a degenerative process that creates a progression of symptoms within the patient who has previously experienced remission from alcoholism or drug dependence. The syndrome causes the patient to become dysfunctional or incapacitated while sober. It manifests itself in a progressive pattern of behavior and terminates in alcohol/drug use or related debilitating conditions.