Relapse Part Three
Zee Badoni
Contrary to popular beliefs, that relapse is a quick, almost situational occurrence, it is actually a slow process that occurs in 3 stages: emotional, mental, and physical. Being aware of these three stages can help prevent relapse before it occurs.
After completing treatment, one of the greatest fears many newly recovering alcoholics and addicts face is relapse. Relapse is very common, even expected for people who are attempting to overcome an addiction. Many people undergo multiple relapses prior to successfully maintaining long-term recovery. Relapsing from alcohol or drugs occurs when an individual is in recovery, or abstinent from their substance of choice, and they return to their previous substance use. Relapse is a process rather than an event. It starts in subtle ways and increasingly gets worse. In order to understand relapse prevention, one must first understand the stages of relapse. Dr. Steven M. Melemis, MD, PhD and Terence Gorski have developed three distinct stages of the relapse process:
Emotional relapse is the first phase of the three phases of relapse. During this stage, the person is not actively thinking about using drugs or alcohol. However, their emotions and behaviors may be setting them up for a relapse down the road.
To prevent getting stuck in the first stage on the road to relapse, it is helpful to ask yourself some questions to gain awareness through self-reflection. Journaling is an excellent place to start. Try asking yourself the following self-reflection questions:
There are four main ideas in relapse prevention. First, relapse is a gradual process with distinct stages. The goal of treatment is to help individuals recognize the early stages, in which the chances of success are greatest [1]. Second, recovery is a process of personal growth with developmental milestones. Each stage of recovery has its own risks of relapse [2]. Third, the main tools of relapse prevention are cognitive therapy and mind-body relaxation, which change negative thinking and develop healthy coping skills [3]. Fourth, most relapses can be explained in terms of a few basic rules [4]. Educating clients in these few rules can help them focus on what is important.
Another goal of therapy at this stage is to help clients identify their denial. I find it helpful to encourage clients to compare their current behavior to behavior during past relapses and see if their self-care is worsening or improving.
These are some of the signs of mental relapse [1]: 1) craving for drugs or alcohol; 2) thinking about people, places, and things associated with past use; 3) minimizing consequences of past use or glamorizing past use; 4) bargaining; 5) lying; 6) thinking of schemes to better control using; 7) looking for relapse opportunities; and 8) planning a relapse.
In bargaining, individuals start to think of scenarios in which it would be acceptable to use. A common example is when people give themselves permission to use on holidays or on a trip. It is a common experience that airports and all-inclusive resorts are high-risk environments in early recovery. Another form of bargaining is when people start to think that they can relapse periodically, perhaps in a controlled way, for example, once or twice a year. Bargaining also can take the form of switching one addictive substance for another.
Clinical experience has shown that occasional thoughts of using need to be normalized in therapy. They do not mean the individual will relapse or that they are doing a poor job of recovery. Once a person has experienced addiction, it is impossible to erase the memory. But with good coping skills, a person can learn to let go of thoughts of using quickly.
Most physical relapses are relapses of opportunity. They occur when the person has a window in which they feel they will not get caught. Part of relapse prevention involves rehearsing these situations and developing healthy exit strategies.
This is also the time to deal with any family of origin issues or any past trauma that may have occurred. These are issues that clients are sometimes eager to get to. But they can be stressful issues, and, if tackled too soon, clients may not have the necessary coping skills to handle them, which may lead to relapse.
These are some of the generally recognized benefits of active participation in self-help groups: 1) individuals feel that they are not alone; 2) they learn what the voice of addiction sounds like by hearing it in others; 3) they learn how other people have done recovery and what coping skills have been successful; and 4) they have a safe place to go where they will not be judged.
Denied users will not or cannot fully acknowledge the extent of their addiction. They cannot imagine life without using. Denied users invariably make a secret deal with themselves that at some point they will try using again. Important milestones such as recovery anniversaries are often seen as reasons to use. Alternatively, once a milestone is reached, individuals feel they have recovered enough that they can determine when and how to use safely. It is remarkable how many people have relapsed this way 5, 10, or 15 years after recovery.
Individuals recovering from various forms of addiction frequently encounter relapses that have gained acceptance as an almost inevitable part of the recovery process. However, the normalization of relapses can reduce the urgency for providers, patients, and support individuals to prevent them from occurring. Countless individuals lose their employment, families, freedom, and even lives as a consequence of relapses. Three of the most common relapse prevention strategies have included therapy and skill development, medications, and monitoring. This activity describes relapse prevention interventions used in helping individuals recover from addiction. In particular, it highlights the role of cognitive-behavioral therapy, medications, monitoring, and social support.
Objectives:
- Describe how cognitive behavioral therapy can help prevent relapses.Explain the role various medications can play in the prevention of relapses.Outline the importance of ongoing monitoring including the pros and cons of various forms of monitoring.Explain the role of various members of an interprofessional in helping to prevent relapses.
Individuals recovering from various forms of addiction frequently encounter relapses that have gained acceptance as an almost inevitable part of the recovery process.[1] However, the normalization of relapses can reduce the urgency for providers, patients, and support individuals to prevent them from occurring. Countless individuals lose their employment, families, freedom, and even lives as a consequence of relapses.[2] Three of the most common relapse prevention strategies have included therapy and skill development, medications, and monitoring.
Many individuals in both the healthcare system and the larger society focus on relapse in terms of the consumption of the alcohol or drug that has been problematic for the individual. However, consumption is the very last step in the relapse, and neglecting earlier events in a relapse prevents more effective intervention at earlier stages.
Relapse prevention is an essential part of addiction recovery. Frequent relapses may prevent individuals from progressing in overcoming their addiction. Although relatively little is known about brain functioning in addiction recovery, sustained abstinence likely allows time for the brain to resume normal functioning that can lay the foundations for long-term success.[3]
An emotional relapse may occur when a person remembers their last relapse, does not want to repeat it, and is not thinking about using. However, their emotions and resulting behaviors are laying the foundations for their next relapse. Individuals in this stage are often not planning to relapse so that they may be in denial of their risk of relapse. This denial can prevent the use of effective techniques to prevent the progression of the relapse.
There are two main goals during this stage. The first goal is to help the patient understand the importance of self-care. The second goal is to help patients recognize their denial so they can further understand the need to take steps to avoid progressing through the stages of a relapse.
Signs of a mental relapse including craving a substance, thinking about people/places/things associated with their use in the past, exaggerating the positive aspects of past use and/or minimizing the consequences of past use, lying, bargaining, trying to plan ways to use while still maintaining control, seeking opportunities to relapse, and planning a relapse.
Providers help patients in this stage to recognize and avoid situations that increase the risk of physical relapse. Participants in this stage may be at a significantly increased risk of a physical relapse during special times, such as a social event, holiday, or a trip when they may use mental bargaining to justify their use.
Some patients early in recovery may set up unreasonable expectations in that they believe they will never again think about using or having a relapse. Providers need to emphasize that occasional thoughts of using or cravings are a common part of recovery so they can help the patient equip themselves with the skills needed to work through these challenges.
The final stage of relapse occurs when an individual resumes the use of the substance. Some researchers have differentiated a "lapse" (an initial use of the substance) from a "relapse" (uncontrolled use of the substance). However, this distinction may be detrimental to some individuals by helping them to minimize the impact of a lapse. As the DSM criteria make clear, most individuals with a substance use disorder have difficulty controlling how much they use, resulting in the likelihood that one drink, for example, will lead to many more if not corrected. Also, an initial lapse can lead to an increased obsession with further use.
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