Relapse Prevention

Recovery is living a meaningful and comfortable life without the need for alcohol or other drugs.  In recovery, the addict moves from a destructive dependence on alcohol or other drugs toward full physical, psychological, social, and spiritual health.  When the addict stops using chemicals, they begin to heal the damage to their bodies, minds, relationships, and spirit.

Recovery is more than just healing the damage.  It is living a lifestyle that promotes continued physical, psychological, social, and spiritual health.

Abstinence from mood-altering chemicals is the first requirement toward recovery.  The addict has to do this before learning what to do to get and stay healthy in all areas of their lives.

Notice that I did not say recovery was abstinence from alcohol and drugs.  Abstinence is only the beginning of recovery.

The addict does not recover overnight.  Recovery is a developmental process.  They go through a series of stages.  The term "developmental" means to grow in stages or steps.  It is a gradual effort to learn new and progressively more complex skills.  A developmental model of recovery means that the addict can grow from simple abstinence to a meaningful and comfortable sobriety.  The addict can confront new problems while abstinent and try to solve them.  Sometimes they fail, and sometimes they succeed.  Whatever the outcome, they learn from the experience and try again.

The skills necessary for long-term recovery are a way of thinking, a way of acting, a way of relating to others.  It is a philosophy of living.  It requires the daily effort of working a recovery program.

The longer they stay sober, the more they need to know to maintain a sense of meaning, purpose, and comfort.  The things they do to stay comfortable at thirty days of sobriety may no longer work for them at sixty days.  It is as if the recovery process forces them to keep growing, learning, and changing.

Abstinence - a necessary first step in learning what to do to get and stay healthy in all areas of life.

Recovery - abstinence plus a return to full physical, psychological, social, and spiritual health.

The journey toward recovery is very clear.  First, the addict stops using chemicals entirely.  Then they begin to associate with others who want recovery.  They listen to others with more time in recovery and practice what they learn in their day-to-day lives.  They fail at some things and succeed at others, but maintain a commitment to learn and grow no matter what happens.  The addict keeps what works and leaves the rest.  They talk honestly about what they tried and what happened.  They learn from those in recovery experiences and share this new knowledge with others.

The developmental model of recovery is based upon a series of beliefs:

1. Recovery is a long-term process that is not easy.

2. Recovery requires total abstinence from alcohol and other drugs, plus active efforts toward personal growth.

3. There are underlying principles that govern the recovery process.

4. The better we understand these principles, the easier it will be for us to recover.

5. Understanding alone will not promote recovery; the new understanding must be put into action.

6. The actions that are necessary to produce full recovery can be clearly and accurately described as recovery tasks.

7. It is normal and natural to periodically get stuck on the road to recovery.  It is not whether you get stuck that determines success or failure, but it is how you cope with the stuck point that counts.

To learn about recovery, it is helpful to divide the process into stages.  The stages of recovery are:  (1) transition, (2) stabilization, (3) early recovery, (4) middle recovery, (5) late recovery, and (6) maintenance.  

During the first recover stage, transition, the addict recognizes they have problems with chemicals, but they think they can solve them by learning how to control their use.  This stage ends when they recognize they are not capable of control (that they are "powerless" over alcohol or other drugs), and are out of control or how to stay sober; they just know they cannot continue the way they have been.  In A.A. this is called "being sick and tired of being sick and tired."

During the second stage, the addict learns they have serious problems with alcohol and drug use and that they need to stop using completely, but are unable to do so.  During this time they recuperate from acute withdrawal (the stage of shakiness and confusion which they experience as their bodies detoxify), and they recuperate from long-term or post-acute withdrawal (the period of time lasting from six to eighteen months when they are in a mental fog).  During this stage they learn how to "stay away from one drink (or one dose of drugs) one day at a time."

The third stage, early recovery, is a time of internal change.  During early recovery the addict learns how to become comfortably abstinent.  The physical compulsion to use chemicals is relieved, and they learn more about their addiction and how it affected them.  They learn to over come their feelings of shame, guilt, and remorse.  The addict become capable of coping with their problems without chemical use.  Early recovery ends when they are ready to begin practicing what they have learned by straightening out other areas of their lives.

During middle recovery, the fourth stage, the addict learns how to repair any past damage and put balance in their lives.  They learn that full recovery means "practicing these principles (the sober living skills learned in early recovery) in all of their affairs."  During middle recovery, they make it a priority to straighten out relationships with people.  They reevaluate their significant relationships, including relationships with family and friends, and their careers.  If they find they are unhappy in any of these areas, they admit it and make plans to do something about it.  In AA terms, this means making amends.  They acknowledge that they have done damage to other people.  They become willing to take responsibility and to do whatever possible to repair it.  Middle recovery ends when the addict has a balanced and stable life.

During the fifth stage, late recovery, the focus is on overcoming obstacles to healthy living that the addict may have learned as a child, before the addiction even developed.  Many chemically dependent people come from dysfunctional families.  Because their parents may not have done a very good job at parenting, they may never have learned the skills necessary to be happy.  Late recovery ends when the addict has accomplished three things.

* First, they recognize the problems they have as adults that were caused by growing up in a dysfunctional family.

  * Second, they learn how to recover from the unresolved pain that was caused by growing up in a dysfunctional family.

  * Finally, they learn how to solve current problems in spite of the obstacles caused by how we were raised.

The sixth and final stage is maintenance.  The addict recognizes that they can never safely use alcohol and other drugs, and they must practice a daily recovery program to keep addictive thinking from returning.  They live in a way that allows them to enjoy the journey of life.

Many chemically dependent people ask, "What are some things I might do that would cause a relapse?"  The answer is simple.  You do not have to do anything.  Stop using alcohol and other drugs, but continue to live your life the way you always have.  Your disease will do the rest.  It will trigger a series of automatic and habitual reactions to life and living that will create so much pain and discomfort that a return to chemical use will seem like a positive option.

Relapse refers to the process of returning to the use of alcohol or drugs after a period of abstinence.  Relapse is a possibility regardless of how much time the addict has been sober.  Part of their recovery plan should include learning about the relapse process and devising a plan to help prevent them from relapsing should warning signs occur.

The addict can be in relapse before they actually use alcohol or drugs.  It is possible to build up to a relapse over a period of hours, days, weeks, or even months.  Many alcoholics and drug dependent persons have reviewed their relapse experiences and identified clues which preceded the relapse, and which indicated they were headed back to using alcohol or drugs.

Relapse is a critical problem facing the field of alcoholism and drug dependence.  Many alcoholic and drug dependent persons become relapse prone in spite of their involvement in the finest available treatment.

The relapse dynamic is an independent and free standing syndrome that activates a process of progressive degeneration in physical, psychological, behavioral, and social functioning.  In the final stages the entire lifestyle is affected as the syndrome is marked by a loss of control over thought process, emotional process, judgement, and behavior.  This loss of control is followed by either a return to alcohol or drug use; physical or emotional collapse; or death by stress related illness, accident, or suicide.

The relapse dynamic is present in some degree of severity in all patients recovering from alcoholism and drug dependence.  In its severe form it is progressive and does not respond to traditional treatment methods.

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.

Relapse Syndrome

The relapse syndrome can be represented as an equation:

Post Acute Withdrawal Syndrome (PAW) is an acute process that creates a progression of symptoms within the patient who has previously experienced clear thinking, clear emotions and clear recent memory recall.  This syndrome causes the patient to become dysfunctional and temporarily incapacitated while in the recovery process.  PAW's are not psychological.  They result from chronic brain and nervous system damage caused by alcoholism; similar to the symptoms exhibited with mild stroke or head injury.

The cause of PAW is a combination of predisposing and precipitating factors.

PREDISPOSING FACTORS:  Creates an atmosphere of high risk.
1. Chemical Produced Health Problems.
2. High Stress Personality Style.
3. High Stress Lifestyle.
4. Inadequate Recovery Program.
5. Social Conflict or Instability.

PRECIPITATING FACTORS:  Creates an immediate cause or trigger.

1. Internal Factors - thoughts, emotions, memories, future projections.
2. External factors - persons, situations, events.

The predisposing and precipitating factors can be viewed as RELAPSE WARNING SIGNS.

What can the substance abuse counselor do to help the recovering person?

1. Strongly emphasize the need to attend an aftercare program. 

2. Encourage frequent contact with sponsor.

3. Encourage frequent attendance at 12 Step meetings (at least once a week, and more frequently in times of increased stress).

4. Show the patient your support and caring in his or her recovery program by acknowledging "dry dates" and anniversaries in recovery. 

5. Look for clues of potential or early relapse and help the patient reverse this process early. THE REVIEW OF RELAPSE WARNING SIGNS

EARLY RECOVERY
Internal Warning Signs of Relapse.
During this phase recovering people experience the inability to function normally within themselves.  The most common symptoms are:

Difficulty in thinking clearly.  Recovering people often have trouble thinking clearly or solving usually simple problems.  At times their minds race with rigid and repetitive thoughts.  At other times their minds seem to shut off or go blank.  They have difficulty concentrating or thinking logically for more than a few minutes.  As a result they are not always sure about how one thing relates to or affects other things.  They also have difficulty deciding what to do next in order to manage their lives and recovery.  At times they are unable to think clearly and tend to make bad decisions that they would not have made if their thinking was normal.

Difficulty in managing feelings and emotions.  During periods of recovery many recovering people, at times, have difficulty in managing their feelings and emotions.  At times they overreact emotionally (feel too much).  At other times they become emotionally numb (feel too little) and are unable to know what they are feeling.  At still other times they feel strange or "crazy feelings" for no apparent reason (feel the wrong thing) and may think they are going crazy.  These problems in managing feelings and emotions have caused them to experience mood swings, depression, anxiety, and fear.  As a result of this, they don't trust their feelings and emotions and often try to ignore, stuff, or forget about them.  At times the inability to manage feelings and emotions has caused them to react in ways that they would not have acted if their feelings and emotions were properly managed.

Difficulty in remembering things.  Many recovering people have memory problems that prevent them from learning new information and skills.  The new things they learn tend to dissolve or evaporate from their mind within twenty minutes of learning them.  They also have problems remembering key events from their childhood, adolescence, or adulthood.  At times they remember things clearly.  At other times these same memories will not come to mind.  They feel blocked, stuck, or cut off from these memories.  At times the inability to remember things has caused them to make bad decisions that they would not have made if their memory were working properly.

Difficulty in managing stress.  Many recovering people have difficulty in managing stress.  They cannot recognize the minor signs of daily stress.  When they do recognize the stress they are unable to relax.  The things other people do to relax either do not work for them or make the stress worse.  It seems they become so tense that they are not in control of it.  As a result of this constant tension there are days when the strain becomes so severe that they are unable to function normally and feel about to collapse physically or emotionally.

Difficulty in sleeping restfully.  During periods of recovery many recovering people have difficulty sleeping restfully.  They cannot fall asleep.  When they do sleep they have unusual or disturbing dreams.  They awaken many times and have difficulty falling back asleep.  They sleep fitfully and rarely experience a deep relaxing sleep.  They awaken from a night of sleep feeling tired and not rested.  The times of day at which they sleep change.  At times they stay up late due to an inability to fall asleep and then oversleep because they are too tired to get up in the morning.  At times they become so exhausted they sleep for extremely long periods, sometimes sleeping around the clock for one or more days.

Difficulty with physical coordination and accidents.  During periods of recovery many recovering people have had difficulty with physical coordination that results in dizziness, trouble with balance, difficulty with hand-eye coordination, or slow reflexes.  These problems create clumsiness and accident proneness that cause other problems they would not have had if their coordination were normal.

Shame, guilt, and hopelessness.  At times many recovering people feel a deep sense of shame because they believe they are crazy, emotionally disturbed, defective as a person, or incapable of being or feeling normal.  At other times they feel guilty because they believe they are doing something wrong or failing to work a proper recovery program.  The shame and guilt cause them to hide the warning signs and stop talking honestly with others about what they are experiencing.  The longer they keep them hidden the stronger the warning signs become.  They try to manage these warning signs but fail.  As a result they begin to believe that they are hopeless.

Return of Denial.  During this phase recovering people become unable to recognize and honestly tell others what they are thinking or feeling.  The most common symptoms are:

Concern About Well Being.  The internal warning signs of relapse make many recovering people feel uneasy, afraid and anxious.  At times they may be afraid of not being able to stay sober.  This uneasiness comes and goes and usually lasts only a short time.

Denial of the Concern.  In order to tolerate these periods of worry, fear, and anxiety, they may ignore or deny these feelings in the same way they at one time denied addiction.  The denial may be so strong that they are not aware of it while it is happening.  Even when they are aware of the feelings, they are often forgotten as soon as they are gone.  It is only when they think back about the situation at a later time that they are able to recognize the feelings of anxiety and the denial of those feelings.

Avoidance and Defensive Behavior.  During this phase recovering people don't want to think about anything that will cause the painful and uncomfortable feelings to come back.  As a result they begin to avoid anything or anybody that will force an honest look at self.  When asked direct questions about well-being, they tend to become defensive.  The most common symptoms are:

Believing "I'll Never Drink Again."  Recovering people often convince themselves that they will never drink or use again.  Sometimes they tell this to others, but usually they keep it to themselves.  They may be afraid to tell their counselor or other AA members about this belief.  When they firmly believe they will never drink or use again, the need for a daily recovery program feels less important.

Worrying About Others Instead of Self.  They may become more concerned about the sobriety of others than about personal recovery.  They do not talk directly about these concerns but  privately judge the drinking of friends and spouse and the recovery programs of other recovering persons.  When dealing with issues of sobriety the recovering person begins to focus more on what other persons are doing rather than upon what he or she is doing.  In AA this is called "working the other guy's program."

Defensiveness.  They may have a tendency to defend themselves when talking about personal problems or their recovery program even when no defense is necessary.

Compulsive Behavior.  They may become compulsive ("stuck" or "fixed" or "rigid") in the way they think and behave.  There is a tendency to control conversations either by talking too much or not talking at all.  They tend to work more than is needed, become involved in many activities and may appear to be the model of recovery because of heavy involvement in AA Twelve Step work and chairing AA meetings.  They may be leaders in counseling groups by "playing therapist."  Casual or informal involvement with people, however, is avoided.

Impulsive Behavior.  Patterns of compulsive behavior begin to be interrupted by impulsive reactions.  In many cases these are over-reactions to stressful situations.  High-stress situations that lasted for a long time generally resulted in impulsive behavior.  Many times these overreactions to stress form the basis of decisions which affect major life areas and commitments to ongoing treatment.

Tendencies Toward Loneliness.  They may begin to spend more time alone.  They usually have good reasons and excuses for staying away from other people.  These periods of being alone begin to occur more often and they begin to feel more and more lonely.  Instead of dealing with the loneliness by trying to meet and be around other people, their behavior becomes more compulsive and impulsive.

MIDDLE RECOVERY
Crisis Building.  During this phase recovering people begin to experience a sequence of life problems that are caused by denying personal feelings, isolating self, and neglecting the recovery program.  Even though they want to solve these problems and work hard at it, two new problems pop up to replace every problem that is solved.  The most common warning signs that occur during this period are:

Tunnel Vision.  Tunnel vision is seeing only one small part of life and not being able to get "the big picture."  Many recovering people look at life as being made up of separate, unrelated parts.  They focus on one part without looking at the other parts or how they are related.  Sometimes this creates the mistaken belief that everything is secure and going well.  At other times this results in seeing only what is going well.  At other times this results in seeing only what is going wrong.  Small problems are blown up out of proportion.  When this happens they come to believe they are being treated unfairly and have no power to do anything about it.

Minor Depression.  Symptoms of depression begin to appear and to persist.  They may feel down, blue, listless, empty of feelings.  Oversleeping becomes common.    They are able to distract themselves from these moods by getting busy with other things and not taking about the depression.

Loss of Constructive Planning.  They may stop planning each day and the future.  They often mistake the AA slogan.  "One day at a time." to mean that they should not plan or think about what they are going to do.  Less and less attention is paid to details.  They become listless.  Plans are based more on wishful thinking (how they wish things would be) than reality (how things actually are).
Plans Begin to Fail.  Because they make plans that are not realistic and do not pay attention to details, plans begin to fail.  Each failure causes new life problems.  Some of these problems are similar to the problems that occurred during drinking.  These typically include marital, work, social, and money problems.  They often feel guilty and remorseful when these problems occur.

Immobilization.  During this phase the recovering person is unable to initiate action.  He or she goes through the motions of living but is controlled by life rather than controlling life.

Daydreaming and Wishful Thinking.  It becomes more difficult to concentrate.  The "if only" syndrome becomes more common in conversation.  They begin to have fantasies of escaping or "being rescued from it all" by an event unlikely to happen.
Feelings That Nothing Can Be Solved.  A sense of failure begins to develop.  The failure may be real or may be imagined.  Small failures are exaggerated and blown out of proportion.  The belief that "I have tried my best and recovery is not working out" begins to develop.

Immature Wish to Be Happy.  A vague desire "to be happy" or to have "things work out" may develop without their identifying what is necessary to be happy or have things work out.  "Magical thinking is used."  They want things to get better without doing anything to make them better, without paying the price of making things better.

Confusion and Overreaction.  During this period recovering people have trouble thinking clearly.  They become upset with themselves and those around them.  They become irritable and overreact to small things.  The most common warning signs experienced during this phase are:

Periods of Confusion.  Periods of confusion become more frequent, last longer, and cause more problems.  The recovering people experiencing this often feel angry with themselves because of their inability to figure things out.

Irritation with Friends.  Relationships become strained with friends, family, counselors, and AA members.  The recovering people may feel threatened when others talk about the changes they are noticing in their behavior and mood.  The conflicts continue to increase in spite of their efforts to resolve them.  They begin to feel guilty and remorseful about their role in these conflicts.

Easily Angered.  They may experience episodes of anger, frustration, resentment, and irritability for no real reason.  Overreaction to small things becomes more frequent.  Stress and anxiety increase because of the fear that overreaction might result in violence.  The effort to control themselves adds to the stress and tension.

Behavioral Loss of Control.  During this phase they become unable to control or regulate personal behavior or daily schedules.  There is still heavy denial and no full awareness of being out of control.  Their life becomes chaotic and many problems are created in all areas of life and recovery.  The most common warning signs experienced during this period are:

Irregular Attendance at AA and Treatment Meetings.  They stop attending AA regularly and begin to miss scheduled appointments for counseling or treatment.  They find excuses to justify this and do not recognize the importance of AA and treatment.  They develop the attitude that "AA and counseling are not making me feel better, so why should I make them a number one priority?  Other things are more important."

Development of an "I Don't Care" Attitude.  They try to act as if they do not care about the problems that are occurring.  This is to hide feelings of helplessness and a growing lack of self-respect and self-confidence.

Open Rejection of Help.  They cut themselves off from people who can help.  They may do this by having fits of anger that drive
others away, by criticizing and putting others down, or by quietly withdrawing from others.

Dissatisfaction with Life.  Things seems so bad that they begin to think that they might as well begin addictive use because things could not get worse.  Life seems to have become unmanageable since drinking has stopped.

Feelings of Powerlessness and Helplessness.  They develop difficulty in "getting started" have trouble thinking clearly, concentrating, and thinking abstractly; and feel that they can not do anything and begin to believe that there is no way out.

LATE RECOVERY
Recognition of Loss of Control.  Their denial breaks and they suddenly recognize how severe the problems are, how unmanageable life has become, and how little power and control they have to solve any of the problems.  This awareness is very painful and frightening.  By this time they have become so isolated that it seems that there is no one to turn to for help.  The most common warning signs that occur during this phase are:

Self-Pity.  They begin to feel sorry for themselves and may use self-pity to get attention at AA or from family members.

Thoughts of Social Drinking.  They realize that drinking or using drugs would help them to feel better and begin to hope that they can drink or use normally again and be able to control it.  Sometimes they are able to put these thoughts out of their minds, but often the thoughts are so strong that they can not be stopped.  They may begin to feel that drinking is the only alternative to going crazy or committing suicide.  Drinking actually looks like a sane and rational alternative.

Conscious Lying.  They begin to recognize the lying, denial, and excuses but are unable to interrupt them.

Complete Loss of Self-Confidence.  They feel trapped and overwhelmed by the inability to think clearly and take action.  This feeling of powerlessness causes the belief that they are useless and incompetent.  As a result, they come to believe that they can not manage life.

Option Reduction.  During this phase recovering people feel trapped by the pain and inability to manage life.  There seem to be only three ways out-insanity, suicide, or addiction use.  They no longer believe that anyone or anything can help them.  The most common warning signs that occur during this phase are:

Unreasonable Resentment.  They feel angry because of the inability to behave the way they want to.  Sometimes the anger is with the world in general, sometimes with someone or something in particular, and sometimes with self.

Discontinues All Treatment and AA.  They stop attending all AA meetings.  If they are taking Antabuse they may forget to take it or deliberately avoid taking it regularly.  If a sponsor or helping person is part of treatment, tension and conflict develop and become so severe that the relationship usually ends.  They may drop out of professional counseling even though they need help and know it.

Overwhelming Loneliness.  Frustration, Anger, and Tension.  They feel completely overwhelmed.  They believe that there is no way out except drinking, suicide, or insanity.  There are intense fears of insanity and feelings of helplessness and desperation.

Loss of Behavioral Control.  They experience more and more difficulty in controlling thoughts, emotions, judgments, and behaviors.  This progressive and disabling loss of control begins to cause serious problems in all areas of life.  It begins to affect health.  No matter how hard they try to regain control, they are unable to do so.

Return to "Controlled" Addictive Use.  At this point many recovering people are so desperate that they make themselves believe that controlled use is possible.  They plan to use chemicals for a short period of time and/or in a controlled fashion.  They begin using the chemical with the best of intentions.  They believe they have no other choice.

Shame and Guilt.  The initial use produces feelings of intense guilt and shame.  Guilt is the feeling that is caused by the self-judgment that "I have done something wrong."  The recently relapsed persons feel morally responsible for the return to use and believe it would not have happened if they had done "the right things."  Shame is the feeling that results from the self-judgment that "I am a defective person."  Many recovering people feel that their relapse proves that they are worthless and that they might as well die as an active addict.

Loss of Control.  The addictive use spirals out of control.  Sometimes that loss of control occurs slowly.  At other times the loss of control is very rapid.  The person begins using as often and as much as before.

Life and Health Problems.  They begin to experience severe problems with their life and health.  Marriage, jobs, and friendships are seriously damaged.  Eventually their physical health suffers and they become so ill that they need professional treatment.

HOW TO OVERCOME THE URGE TO RELAPSE

Recovering addicts have used a number of practical methods to help them survive urges or cravings to use alcohol or drugs.  These methods are listed below:

Talking with others.  Talk with someone face-to-face or on the telephone, such as a friend, family member, AA/NA sponsor, minister, or counselor.  Attend an AA/NA meeting.  Request an appointment if in counseling.  Keep names and phone numbers in your wallet.

Redirecting your activity.  Get involved in an activity such as going for a drive, working around your home, going to a movie, working out in some physical manner.  Occupy yourself with reading.  Write your thoughts and feelings in a journal.  Get something to eat.  Pray.  These activities may also help you relax.

Changing your thoughts.  Tell yourself that you will put off using alcohol or drugs until tomorrow.  Think of all the bad things which have happened to you as a result of your alcohol or drug use.  Think of how good you will feel if you do not use.  Think of all the benefits to your sobriety, both now and in the future; write these down on paper if needed.  Think positively:  "I'm not going to use," or "I will get through this urge or craving without using."  Repeat some of the recovery slogans such as "one day at a time," "easy does it," or "this too will pass."  

Avoid threatening situations.  Don't go to bars, parties, or clubs where you think it will be even more difficult to handle your urge or craving.  Avoid socializing with others whom you know may influence you to use alcohol or drugs. 

IDENTIFYING AND HANDLING SOCIAL PRESSURES

Many recovering alcoholics and drug dependent persons have stated that a variety of social pressures must be successfully handled in order to maintain sobriety.  Social pressures may be direct such as being offered alcohol or drugs, or indirect such as being involved in a family gathering or work related function where alcohol or drugs are being used.  Successful recovery will require the addict to be aware of how they might be affected by these various social pressures and what they can do to deal with these pressures without using alcohol or drugs. 

There are many social pressures which the addict may experience during recovery.  For example, a New Year's party, or being invited to a bar for a game of pool.  In these situations the addict may experience any number of feelings or thoughts which could trigger a relapse. 
There are many social pressures which may be experienced during recovery; for example, your son's graduation party, your niece's wedding, a Christmas party at work, a bowling banquet, etc.  Remember, when these situations occur, the addict may experience any number of feelings or thoughts which are uncomfortable.  For example, they may feel their sobriety is threatened and feel anxious; they may feel angry that they don't fit in with their old group of friends or associates; they may feel a sense of self-pity that they can't use alcohol or drugs; or may think, "one or two won't hurt."

In early recovery many social pressures to use alcohol or drugs may be avoided simply by planning day-to-day activities around non-chemical events and environments.  Staying out of bars or not attending parties where others are getting high are examples of how the addict may avoid some of these pressures.  However, there is no way to avoid all social pressures to use alcohol or drugs so the addict may want to rehearse ways of handling these situations.  Review the following ways others have handled social pressures to use alcohol or drugs.

1. State straight out that you have a problem with alcohol or drugs .

2. Simply refuse the offer without giving an explanation. 

3. State that you are not using today.

4. Request the person offering not do so because of the problems your alcohol and drug use have caused. 

5. Offer an alternative activity if you would like to spend time with the person who requests your company going to a bar.  For example, state, "I'm not drinking.  Let's go get a cup of coffee."

If the addict begins to feel increasingly anxious in a social situation then it is advisable to physically leave the situation if possible.  This is especially important if the people who may be present have an ability to influence the addict to use alcohol or drugs. 

LIFESTYLE BALANCING AND SOBRIETY

Recovery from alcohol and drug problems requires abstinence from mood altering drugs and changes in lifestyle.  The specific areas of change will depend on the addict's unique situation, but healthy recovery should involve a reasonable "balance" in the different areas of life.  Review the following areas: 

1. Continued Treatment.  The addict should plan to continue treatment for their drug problem.  This includes participation in AA/NA, counseling or other special services.  Family should also be involved as needed. 

2. Physical Health.  Maintain physical health through proper nutrition and eating habits, physical exercise and proper rest as well as regular physical and dental examinations. 

3. Recreational/Leisure.  Interests which are constructive and do not evolve around alcohol or drug use need to be developed.  The addict needs to have fun and enjoy a variety of recreational and social activities. 

4. Relationships.  Personal relationships with others such as family members, friends, and others should be nurtured.  When possible work on "making amends" to those hurt as a result of the addiction.  Develop new relationships with sober people.  Eliminate friendships with people who pose a threat to continued sobriety. 

5. Work or School.  Developing occupational or educational goals suited to the addicts abilities and interests is very important. 
6. Spirituality.  Use meditation or prayer or by participating in your religious faith. 

7. Psychological Heath.  Encourage the addict to improve how they feel about themselves by making positive changes:  changing negative thought and behavior patterns; appropriately expressing emotions, developing coping skills and problem solving skills.  Encourage the addict to take regular inventories of strengths and weaknesses to determine which areas they need to change. 

WHAT TO DO WHEN YOU HAVE AN URGE TO GET HIGH

1. Remember the principles of deaddiction  Craving means the addict is not fully deaddicted.  Experiencing drug urges but not giving in to them brings the addict closer to ending them.  
2. Think about the consequences of using.  Drug use will:
prolong the disease;
make the urges stronger and harder to handle next time;
cause guilt and shame;
cost a lot of money;
increase contacts with other users;
risk a full-blown relapse;
and who knows what else?

3. Consider what's causing the urge.  Is the addict in a dangerous situation, cash in hand, the presence of drug users or drug offers or old drug settings, war stories, loneliness, or boredom?  What else is going on inside or around the addict?

4. The addict should leave the situation immediately.  Go somewhere else, or do something else they like to do; eat, see a movie, listen to music, work out, or get together with other people who don't get high.  As long as the addict doesn't dwell on it, the urge is likely to last no more than a few minutes.  Wait it out. 

5. Get help.  Contact someone who's clean, strong, and dependable.  Be honest with them and listen to them. 

WHAT TO DO IF A RELAPSE OCCURS

The first thing the addict will want to do should they use alcohol or drugs following a period of abstinence is to tell themselves that they must stop using immediately.  Tell the addict it is important to get back on the sober track.  Discuss the return to alcohol or drug use immediately with some other concerned person such as a family member, AA/NA sponsor, counselor, minister, or friend. 

If the addict has returned to use after quitting or reducing treatment activities, decide if they need to return to these or increase participation.  They can anticipate feeling guilty and disappointed after using drugs or alcohol again.  But it is important not to allow these feelings to give permission to continue using.

If the addict has been using alcohol or drugs over a period of weeks or months and feels unable to stop in their own, then consider seeking professional help.  Contact a local drug or alcohol clinic or hospital and ask for an evaluation.  This can help determine if the patient needs detoxification, other specialized inpatient treatment, or outpatient treatment.  If any withdrawal symptoms are experienced after stopping or significantly reducing alcohol or drug use, the patient may need to be detoxified in a hospital setting.  Withdrawal symptoms associated with alcohol and other depressants may be life threatening in some instances. 

After a return to alcohol or drug use the addict should contact someone for help.

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