Mark Twain once said, “Giving up smoking is easy…I’ve done it hundreds of times.” The quote illustrates the confounding nature of addiction; while it may be difficult to stop an addictive behavior, it’s even harder to “stay stopped.”
What Does the Term “Relapse” Really Mean?
If you ask someone impacted by addictive illness or someone in the medical field about “relapse”, they will most likely describe it as going back to an active state of substance use after period of remission.
What many people don’t realize is that chemical use is not the beginning of a relapse, but the final step of an ongoing process. Fortunately, rates of relapse can be lowered if recovering people are exposed to education and training about relapse prevention and how to deal more effectively with all of their coexisting problems. Prevention is always much easier than crisis management. Understanding the dynamics can also serve as a form of Harm Reduction-limiting the harm an individual does to themselves when they fall short of their recovery goals.
Relapse is the Process of Becoming Dysfunctional in Recovery
Relapse education must start with a new definition: relapse is a progressive series of events that takes someone from stability through various stages of dysfunction, and eventually back to using drugs problematically.
People who struggle with relapse can benefit from carefully examing their underlying mistaken beliefs, negative thoughts, uncomfortable emotions, self-defeating behaviors and dysfunctional social reactions. This goes beyond identifying the cues that may trigger drug use. While it is important to recognize the “people, places and things” that may trigger an addictive response, the more challenging task is to identify the overall pattern.
The pattern is comprised of a series of identifiable stages which unfold over time and ultimately leave the person highly vulnerable. Much of this process lies just below conscious awareness. Most people don’t intentionally plan their return to substance use. From the person’s point of view, it just seems to happen without warning. But there are always indicators that trouble is brewing.
Understanding the Difference Between a Slip and a Relapse
People who identify as being “in recovery” sometimes use the terms “slip” and “relapse” interchangeably. However, there are important differences. A slip, also known as a lapse, is an undesired episode of drug use after a sustained period of abstinence. This could be a one-time occurrence, or several uses within a short period of time. A relapse is a full-blown return to addictive behavior where the person often loses the gains they’ve made.
What determines whether a person stops using after a slip or allows their drug use spiral out of control? The answer lies in the how the individual interprets their drug use.
It’s common to feel discouraged, remorseful, ashamed and confused by a return to use. For some, a brief lapse causes so much self-doubt and a sense of personal failure, that the person gives up all recovery efforts. These individuals experience a severe reaction to falling short of their recovery goals. They mistakenly believe that any drug or alcohol use requires them to “hit bottom” and they need to start over in recovery from the beginning. This belief inevitably leads to continued drug use and a head-long dive into oblivion. Dr. Alan Marlatt, who was director of the Addictive Behaviors Research Center, at University of Washington identified this tendency as the abstinence violation effect.
But if a person regards a slip as no more than a temporary setback, an unwanted bump in the recovery road but not the end of the world, it is unlikely to escalate further. If a slip is seen as a learning opportunity the recovering person can reframe their setback as a valuable experience, a chance to learn about their addictive illness and improve the quality of their recovery.
After all, the addictive illness has just come into the open and revealed itself. There is much to learn about one’s particular addictive tendencies. Ironically, a return to drug use after a period of sobriety can provide a blueprint for a more effective recovery plan.
Fear of the Unknown
“Cunning, baffling and powerful” is a description of alcohol addiction that appears in the book Alcoholics Anonymous from which the group takes its name. When Bill Wilson, the co-founder of A.A. wrote these words, his intention was to warn members that they were battling a formidable foe. Alcoholism was viewed as a mysterious force with almost supernatural power. It’s not surprising, then, that AA’s solution was for members to find a “higher power” for both protection and deliverance.
Unfortunately, this characterization may predispose some members to a constant state of fear, hypervigilance and uncertainty- a state of prolonged stress that can contribute to a relapse occurrence.
Relapse Prevention work aims to de-mystify the relapse process so that individuals in recovery don’t have to live in fear of the next drink or drug, but instead in awareness of their patterns of becoming dysfunctional in their recovery.
Relapse Is Predictable
If an event is predictable it follows an established pattern. We know in advance that it will happen unless corrective measures are taken. By changing the word “powerful” to “predictable” we’re suggesting that a return to alcohol or drug use can be avoided if one learns to recognize their unique relapse warning signs and how to manage them. While relapse patterns are often similar, they are also unique to each individual. Like a fingerprint, each person has a specific addictive profile.
The knowledge that relapse follows a predictable course is empowering for relapse prone individuals and has multiple implications. As people become mindful of their specific relapse pattern, practice coping skills and see that it’s actually possible to stop a relapse dynamic in its tracks, significant changes occur. The most common are:
- No longer feeling defenseless against drug urges or thoughts of using
- Feel confident in one’s ability to handle challenging situations
- Start believing that continuous recovery is possible
- Become optimistic about the future
Individuals shift from a passive “victim” mentality to being a proactive survivor of addiction. In short, they start feeling hopeful and hope can be a powerful factor in recovery.
Most people who struggle with relapse are only aware of the final stage of the relapse process — the moment they succumb to urges and resume their addictive behavior. However, a return to alcohol or drug use after a period of sobriety is preceded by a complex process. More than just taking a drink or using drugs, relapse results from a progression that creates an overwhelming need for those substances.
Flirting with Danger
To illustrate how relapse is a complex process, not an event, consider the following scenario. Imagine a man is walking along the sidewalk. He stops to light a cigarette and suddenly a piano falls on his head. That would be an event- something that happens at a particular moment in time. To a casual observer, it seems like incredibly bad luck. But if this accident is part of a relapse cycle, the unsuspecting individual missed a variety of early warning signs that would have signaled danger – perhaps a roped off area or a sign stating the danger.
What Was the Process That Preceded the Piano Mishap?
First, the man was feeling listless and bored with life. He yearned for some kind of excitement but wasn’t sure why.
Second, he didn’t talk about how he was feeling or voice his concerns to anyone. Instead, he started going for long walks.
Third, as he walked around the neighborhood, he was drawn to a particular street. The man spent most of the day pacing back and forth on the sidewalk.
Fourth, he started neglecting work, missing meals and lost interest in leisure activities.
Fifth, friends and family warned him that the street was dangerous, but he rejected their concerns, saying that they should mind their own business.
Sixth, during his walks, the man only looked straight ahead- as if he were wearing blinders and thus missed the roped off area and danger signs. He never looked up and didn’t noticed that there was a piano suspended in mid-air
Seventh, if he had greater awareness, he might have noticed that the rope holding the piano had begun to fray days before it broke.
Eighth, the substance he craved was “danger”. Even though he never looked directly at the suspended piano, he felt something exhilarating about walking that way.
Ninth, he also sensed that there was something wrong with his behavior but could not identify what it was. This led to a sense of confusion and paralysis.
Tenth, the paralysis made him come to an abrupt stop…directly below the piano. As he smoked the cigarette, he heard the rope break. Finally, he looked up as the piano hurtled towards him.
There was a remote chance he could have jumped out of the way, but it was unlikely given how long he was flirting with danger. This would be analogous to the moment before an addict buys drugs, an alcoholic orders a drink or a gambler places a bet.
If the man survived, his first question would be “what happened” or “how did this happen?” He might conclude that he was just “in the wrong place, at the wrong time”. This is partially correct. The more important question to consider is how he got to that point. What were the progression of warning signs? How did feeling bored and wanting some excitement in his life play into the relapse dynamic?
In retrospect, there were quite a few early warning signs (the process) that preceded the piano dropping on his head (the event). We see the importance of catching the relapse process before it reaches critical mass. Once individuals learn to identify relapse warning signs, they can begin to manage or avoid them. This concept is the core of Relapse Prevention Therapy (RPT) and Gorski’s Relapse Prevention Therapy Workbook provides a detailed framework for identifying the stages of relapse and creating a relapse prevention plan.
Effective treatment for a relapse prone individual requires a careful investigation of their relapse pattern. The pattern emerges from what the individual recalls, but also involves factors that lie just below awareness. A clearer picture emerges as someone begins to survey their emotional terrain and the contributing behaviors that didn’t seem important at the time.
Conducting a Relapse Autopsy is Crucial
So, if relapse is a process rather than an event, how does one identify their unique pattern and interrupt it early on? Start by asking the simple question, “what happened”? Ask this from a detached perspective, as if you were a scientist studying some natural phenomena. Adopt an attitude of curiosity and wonder rather than self-condemnation. The goal is greater awareness. Write a list of personal warning signs that lead you from stable recovery back to chemical use. Focus less on the moment of use; you are more interested in identifying the factors which led to that point.
- What were the stressors that were not sufficiently addressed?
- Were there any irrational thoughts that you could have disputed?
- Is there a primary emotional response that triggers your addictive act?
- Can you identify the absolute earliest moment when the thought of drug use entered your mind?
- Did you dismiss the thought of drug use as ridiculous or deny the possibility of using drugs again?
There is never just one warning sign, but usually a series of signs that build on one another. It is the cumulative effect of these factors that wears the individual down.
Relapse does not happen when the addict takes the first drink or drug. Relapse is a process that culminates in drug use. The relapse process causes the addict to feel pain and discomfort which in turn distorts the ability to think clearly. The pain and discomfort can become so intolerable that the addict becomes unable to live normally when not using.
- The relapse process does not only involve the act of taking a drink or using drugs. It is a progression that creates the overwhelming need for alcohol or drugs.
- An important part of Relapse Prevention is recognizing the people, places and things associated with one’s addictive behavior. Just as critical is recognizing the emotions and thoughts that make up the relapse dynamic.
- Individuals who’ve made numerous attempts to recover from an addiction don’t need to try harder. They need to try “different.” And the difference is revealed through a thorough assessment of all the factors that compose their relapse dynamic.
Lastly, if you’re walking down the street one day and you see a piano dangling in midair… walk the other way!
About the Authors
Terence T. Gorski
Terence T. Gorski is the Founder and President of The CENAPS Corporation. He is an internationally recognized expert on substance abuse, mental health, violence, and crime. He is best known for his contributions and expertise to relapse prevention, managing chemically dependent offenders and developing community-based teams for managing the problems of alcohol, drugs, violence, and crime. He is a prolific author, and has published numerous books and articles, including Staying Sober - A Guide For Relapse Prevention, The Staying Sober Workbook and the Relapse Prevention Therapy Workbook.
Spero Alexio is a writer and clinically trained psychotherapist with a virtual counseling practice located in Las Vegas, Nevada. He is considered both an expert in the dynamics of relapse and a pioneer in non-traditional drug treatment. He developed Qtherapy, a form of exposure therapy that neutralizes the cues associated with addictive behavior. Mr. Alexio also provides aftercare for individuals who have detoxed with Ibogaine and other plant medicines.
Phone: (702) 204-9472
Special thanks to Dr. Stephen Grinstead for his support with this article and contribution to the field of Relapse Prevention.
Photo Credit: John Lund