Learning from the Relapse

My goal is to meet my patient where he’s at. If he isn’t ready to try abstinence, we work from that position—embracing harm reduction techniques and keeping an eye on the benefits and consequences of being a “social drinker.” This article, however, assumes the patient has been abstinent, has relapsed, and wishes to return to abstinence.

How was it?

Usually, a return to my office suggests the relapse did not end well. But I need the patient to articulate that, so I ask: How was the relapse? Did you have fun? Why are you here with me? When he shares that “It didn’t get any better out there,” we can explore what led to the decision to use.

Usually my client is confused, uncertain about what made using seem like a good idea. “I did it again! How did that happen?” This is why a “relapse reconstruction” can serve as a major foundation as we build a defense against the next drink/drug.

Was it a moment of simply not caring? Was it a belief that the relapse would not be discovered and no harm would come? Did romance cause distraction? Did a resentment cause an angry relapse? Did euphoric recall blur judgment?

What were you doing?

When I ask what happened, many addicts are unable to identify a precise cause and effect. The response is usually something like, “I don’t know, it just seemed like a good idea at the time,” or “I missed the good times.”

I start with the moments immediately leading up to the use:

• Who were you with?

• Where were you?

• What were you thinking when you picked up?

The answers to these questions can reveal quite a bit. If my client was with unsafe people or in a dangerous place, these are things she can avoid in the future. Note: Even if the unsafe people are family, there are ways to avoid them, in order to create a new family of stable individuals. This is, after all, a deadly disease. Saying goodbye to family members, although difficult, may have to be done.

Very often, there are signals that a relapse is imminent, but those signals can be subtle and difficult to recognize, and can be present weeks and months before the actual relapse. It’s important to explore:

• Gambling (buying scratch tickets is big with the population we serve).

• Changes in eating habits.

• Mood swings (depressive or manic episodes).

• Elevated anxiety.

• Aggressive behavior.

• Adrenalin-inducing activities (stealing, skydiving, etc.).

• Buying things not really needed.

• Changes in sexual habits.

• Spending time with online gaming or watching porn.

• Spending too many hours at work or the gym.

Many addicts “innocently” fall into these habits, failing to recognize them as manifestations of the disease. “At least I’m not drinking” is a common response when someone mentions these behaviors to the addict. In reality, the behaviors—switched addictions—are an attempt to fill the void once filled by the drug use.

What weren’t you doing?

This is the area of greatest opportunity for the addiction professional, because there are myriad ways to fortify one’s sobriety, but they do require action. I try to maintain silence when my patient tries to enumerate things he could have been doing differently. Patients need time to frame their thinking and to identify what wasn’t happening.

I believe the most common and important variable is the lack of safe, sober people in the addict’s life. Creating a network of stable people can take time and effort, and many addicts in early recovery are uncomfortable in social situations. But there are ways to meet and bond with stable people, such as night school, church, self-help groups, volunteering, etc.

AA, NA and SMART Recovery meetings offer a wonderful opportunity to meet like-minded individuals who have learned how to stay sober and to have fun. Without seeming to promote AA, I work with patients to help them make the best use of that fellowship. In that regard, there’s much to be examined:

• Do you have a home group?

• Do you have a job (like coffee maker) in that group?

• Do you have a sponsor?

• Do you attend enough (three? five?) meetings each week?

• Do you sit up front at these meetings?

• Do you show up early to participate in the meeting-before-the-meeting?

• Do you have any friends in recovery?

• Do you stick your hand out to the newcomer?

Obviously, a negative response to any of these questions creates an opportunity for behavioral change. I’ll try to get my patient to agree to one or more of these activities in the immediate future.

Exercise and nutrition also are topics that present opportunities for the newly recovering. Encouraging patients to practice basic self-care habits is certainly appropriate for any addiction professional.

Finally, medication compliance must be examined—not only meds to treat substance use and other mental disorders, but also those to treat physical ailments. Ideally, the addiction professional will have an ongoing dialogue with the prescribers.

Let us not forget that we’re dealing with a brain disease. Logic and willpower are not likely to yield long-term success. In my experience, learning from a relapse is a golden opportunity to create new behaviors that support a recovery lifestyle. Relapse is not part of recovery—it’s part of the disease. Let’s learn from it.

Brian Duffy, LMHC, LADC-I, is a mental health counselor at SMOC Behavioral Healthcare in Framingham, Mass. His email address is bduffy@smoc.org.