Back to basics to prevent relapse
Jessica has been given every opportunity to get sober. Her parents got her help as soon as they realized she had a problem. She has visited numerous detox centers, the best treatment centers in the country, and highly respected sober living programs, she has participated in monitoring efforts, her family has worked with interventionists and case managers, they’ve tried tough love, they’ve supported her, they’ve not supported her … and Jessica continues to relapse.
Dawn has used up all her resources—she’s been to every treatment center for the indigent in her surrounding area at least twice, she has spent time at numerous homeless shelter rehab programs, she’s been on methadone and Suboxone, she’s been in and out of the local Alcoholics Anonymous (AA) group for years, and her state funding has run out so she can’t get any more treatment … and Dawn continues to relapse.
Everyone seems to have a theory as to why individuals such as Jessica and Dawn continue on a cycle of chronic relapse. Some of these theories are more popular than others, while some come and go depending on the decade. Here are some examples.
Theory #1: Relapse happens because that is how individuals are conditioned. With repeated aversion therapy, drugs and alcohol will lose their appeal.
Theory #2: Relapse happens because of failure to cope with a triggering situation, and can be prevented by intervening at different points in the chain of behaviors.
Theory #3: Relapse happens because an individual is self-medicating a mental illness. Chemical dependency is a secondary symptom that will disappear when the underlying mental illness is adequately treated.
Theory #4: Relapse happens because an individual doesn’t have enough self-will, good habits and moderation. These things can be learned.
Theory #5: Relapse happens because an individual is still ambivalent and is not ready to take action to change. A professional can help an individual move through the stages of change with good technique.
Theory #6: Relapse happens when an individual has unresolved issues with trauma. When these issues are resolved, the individual finally will get well.
Theory #7: Relapse happens because of uncontrollable cravings. With the right medications, cravings will go away. Clients may need maintenance drugs for the rest of their life.
Theory #8: Relapse happens because an individual failed to avoid old people, places and things.
Theory #9: Relapse happens because individuals don’t know how valuable they are and don’t believe in themselves or love themselves (this is a favorite theory of mothers throughout the years). With enough affirmative self-talk and new beliefs, they will break the cycle of chronic relapse.
Most treatment professionals would agree that they align themselves with a few of these theories and that the core issues vary with each individual. So, with all of these amazing theories and techniques in our toolkit, why does it seem that relapse still occurs at such epidemic rates?
Spiritual void
Let’s look back at some theories of chronic relapse that I did not already cover, coming from the 1930s during the genesis of AA. William D. Silkworth, MD, was director of Charles B. Towns Hospital for Drug and Alcohol Addictions in New York City, then one of the most well-known hospitals in the country for treating addiction. Silkworth, the first physician to endorse the program of AA, believed that relapse happens because an individual has insane thinking regarding alcohol even when sober and feels emotionally and spiritually uncomfortable without the ease and comfort of alcohol. The only way to stop the cycle of relapse, then, is to have psychic change through a spiritual experience.
Carl Jung, the founder of analytical psychology, also developed a theory on relapse into addiction. Jung’s theory on relapse, which was also discussed in the Big Book of AA, was that relapse happens because of a void for God. Spirituality is the only way to combat alcoholism, Jung believed, and a “vital spiritual experience” is absolutely necessary for a chronic relapser to get and stay sober.
Jung in the Big Book described a spiritual experience as “a huge emotional displacement and rearrangement. Ideas, emotions and attitudes which were once the guiding forces of the lives of these men are suddenly cast to one side, and a completely new set of conceptions and motives begin to dominate them.”
Silkworth and Jung both admitted that despite years of effort, they remained inadequate when treating this certain type of hopeless alcoholic, and that creating a powerful spiritual realignment was far beyond the human power they possessed. They both were very clear that a spiritual experience is necessary to end the cycle of chronic relapse. In addition, they both endorsed the 12 Steps as the best way to induce or create a spiritual experience, which is exactly what the Steps were designed to do.
Research supports Silkworth and Jung’s theory that a spiritual experience is necessary for lasting sobriety. A 2011 study published in the Journal of Studies on Alcohol and Drugs found that changes in spirituality at six months could predict better drinking outcomes at nine months.1
Another 2011 study assessed 1,726 alcohol-dependent individuals at treatment intake and at 3, 6, 9, 12 and 15 months regarding their 12-Step meeting attendance, their spiritual practices and their success in staying sober. The assessments found that 12-Step attendance was clearly associated with an increase in spiritual practices, especially for those who engaged in few spiritual practices before joining the study. In this study, results showed that AA was consistently linked with better sobriety outcomes, which researchers found was partly due to the increase in spirituality.2
In my experience, most chronic relapsers have never worked all 12 Steps. Despite all the treatment they have received, they have missed the longstanding and most basic protocol for addiction in the last century. How is this being missed? In the midst of all the various theories on relapse, has the treatment profession moved away from the theory that was brought to us by the founding fathers of AA, which remains the largest revolution in the history of addiction treatment?
Barriers to success
Most chronic alcoholics and addicts simply cannot stay sober long enough to work all 12 Steps. They also do not understand how the Steps will help them get sober, and therefore they lack motivation.
Also, the 12-Step fellowships don’t always make it a priority to get newcomers through the Steps. It is unfortunate when a desperately ill individual sits in 12-Step meetings for months and is never taken through the Steps by the members of the fellowship. Finally, many treatment professionals are not endorsing the 12 Steps as the way to freedom.
While chronic relapsers require a spiritual rearrangement, treatment or professional help is often necessary as well. This may seem confusing given that professionals have had little impact on chronic alcoholics and addicts. But if treatment providers understand that their most important job is to help them remove all blocks from working the Steps, this can be very powerful. Research has shown that the most success in achieving sobriety happens when the 12 Steps are combined with chemical dependency treatment.3,4
Residential treatment providers can offer a safe environment for a client to stay sober long enough to work the Steps thoroughly. Treatment providers can ensure accountability in completing all 12 Steps. Counselors can work with clients on emotional and clinical issues that arise while working the Steps. Clinical staff members can use their skill to lead clients into taking responsibility for their own actions, a necessary principle of the Steps. If the focus remains on the priority of working all 12 Steps and having a spiritual awakening, clinical support can be an amazing tool.
Many treatment centers claim that they embrace a 12-Step philosophy, yet engage in techniques and teaching methods that directly contradict the Steps. How can we teach a client to make better choices, when Step 1 explains that powerless means we have lost the power of choice? Why are we telling clients to know and avoid their triggers, when the Big Book does not support this? These mixed messages can leave clients baffled as to why they keep relapsing.
It is important that treatment providers be consistent in their philosophical message and make sure all staff members are unified in their messaging. Research has shown that if a treatment center’s philosophy is aligned with the 12 Steps, an individual is more likely to be involved in the fellowship and have better success.5,6
Organizational change
So how does a treatment center align itself with the 12 Steps? The substance of a treatment center is found in its staff members, the vehicles for carrying through its philosophy. Therefore, it is imperative that staff members be selected carefully, and based on how aligned they are with the philosophy of the organization.
If clinical staff members have had personal experience with the 12 Steps, it can be a powerful testament to support the work at hand. It is also essential that continued monitoring and training be consistent, to ensure that the philosophy of the organization is being carried forward.
The 12 Steps can be woven into every facet of an organization if the leadership has that vision and is willing to align itself courageously with the 12-Step philosophy. The curriculum, treatment plans, schedule and off-campus activity all can be centered around the Steps. Treatment plans can be developed for each Step to support the work a client is doing with a sponsor. These treatment plans can encourage clients to dive deep into the Big Book and can help keep them accountable to understanding (and hopefully experiencing) each Step in a real way.
Education classes can always be centered around 12-Step principles, spiritual disciplines, sponsorship, carrying the message to hospitals and institutions, and membership in a 12-step fellowship. Teaching a client about business meetings and group conscience, how to start a meeting, how to carry the message to others, and the 12 Traditions are important tools to prepare them for a lifetime of involvement in the fellowship.
No matter how clinical or emotional a process group is, clinical staff can always weave 12-Step principles into group. When a client is angry, write a four-column inventory with him/her, as directed in the Big Book, and show the person how to practice the Steps in the moment. When a client is in fear, have the client write a fear inventory.
A real-time application of the Steps is invaluable. When a client has a fight with his/her roommate, show the client how to practice Step 10 by opening up the Big Book and following the Step 10 instructions. Individual sessions with clients can always be steered toward taking responsibility for one’s behavior and the application of each step. Chores and daily tasks are very reflective or where a client is at with Step work, surrender, willingness and honesty—this constitutes a great opportunity to work with clients.
Pick strong 12-Step meetings to take clients to within the local community, support clients in finding solid sponsors, align with their sponsors through regular communication, and facilitate opportunities for them to meet with and talk to their sponsors. Take them to 12-Step conferences, have speakers come in to do Big Book workshops, and have morning meditation groups and evening review groups. Do not be afraid to talk about God, and encourage clients to pray. With one voice, the community 12-Step fellowships can come together with local treatment centers to help chronic relapsers find freedom.
Dawn and Jessica are both sober today. They will tell you that they are amazed that they used up so many resources, yet never worked all 12 Steps until they finally went to a treatment center that required them to work the Steps and get involved in a local fellowship.
Heidi Voet Smith, MA, LPC, is Clinical Director for Burning Tree Recovery Ranch in Kaufman, Texas, specializing in working with addicts with a history of chronic relapse. Her e-mail address is hvsmith@burningtree.com.
References
1. Robinson EA, Krentzman AR, Webb JR, et al. Six-month changes in spirituality and religiousness in alcoholics predict drinking outcomes at nine months. J Stud Alcohol Drugs 2011;72:660-8.
2. Kelly JF, Stout RL, Magill M, et al. Spirituality in recovery: a lagged meditational analysis of alcoholics anonymous’ principal theoretical mechanism of behavior change. Alcohol Clin Exp Res 2011;35:454-63.
3. Weiss RD, Griffin ML, Gallop RJ, et al. The effect of 12-step self-help group attendance and participation on drug use outcomes among cocaine-dependent patients. Drug Alcohol Depend 2005;77:177-84.
4. Dawson DA, Grant BF, Stinson FS, et al. Estimating the effect of help-seeking on achieving recovery from alcohol dependence. Addiction 2006;101:824-34.
5. Weiss RD, Griffin ML, Gallop RJ, et al. Self-help group attendance and participation among cocaine dependent patients. Drug Alcohol Depend 2000;60:169-77.
6. Tonigan JS, Connors GJ, Miller WR. Participation and involvement in Alcoholics Anonymous. In Babor TF, Del Boca FK (eds). Matching Alcoholism Treatment to Client Heterogeneity: The Results of Project MATCH. New York City: Cambridge University Press; 2003.
