Relapse/Relapse Prevention: Part 1 of 3
For the Problematic Drug User
Relapse. It’s THE most scary word in addiction treatment, one that we all get nauseous when we hear it, because we all worry about the return of problematic drug use (recurrences/relapse) especially during times of stress for our loved ones with a history of substance use disorders. And right now, we’re in the most stressful time we’ve ever seen. The other word we talk about a lot now when discussing problem drug use and recovery is “connectedness.” We know it’s one of (if not THE) most important ingredients to successful recovery of any kind and mental wellness for humans. So how the heck do we “connect” and otherwise avoid “relapse” during the worse pandemic our modern world has seen? And “herein lies the rub,” as Shakespeare (sort of) famously said!
First off, let’s start with a definition of “relapse”. Many professionals have suggested that we stop using this word as it’s pretty meaningless and very confusing but let’s look at what it typically means. Relapse has been used as a term within addiction treatment for a long time. Ironically, for a country who claims to see addiction as a disease, we don’t discuss “relapse” in any other medical care: we usually use the term “recurrence.” Think diabetes care or cancer, two conditions that are often used for comparison for the disease model of addiction. We don’t say someone relapsed in/on cancer or diabetes, right? We might say the condition has reappeared, or there’s a recurrence of the condition or symptoms. So how did this word get used for this other “disease?” That’s actually up for some debate as it doesn’t appear to have been first used by the medical community which was originally thought. Rather, it seems to have come
 There are many sources for this but here’s one terrific one re: well being in general: http://ccare.stanford.edu/uncategorized/connectedness-health-the-science-of-social-connection-infographic/
from the moral community during the Temperance Movement. My background is in Relapse Prevention. I studied with Terence Gorski and ran many groups on this topic (for Kaiser as well as other hospitals and treatment providers) over the years and my private practice was first called “Relapse Prevention Systems”. In the mid-1990’s, I even did my Master’s project on Relapse Prevention which is how I became acquainted with the foremost authority on relapse prevention and the author of the first book on the subject, Relapse Prevention, the late Dr. G. Alan Marlatt. Another famous American researcher on addictions, Dr. William Miller (developer and co-author of Motivational Interviewing) also spent a great deal of his career looking at this phenomena. What these men found is truly fascinating and likely shocking to some. Two predictors appear to highly influence whether a client returns to old behaviors:
- A lack of coping skills
- A belief in the disease concept of alcoholism (emphasis mine)
Wow. Surprised by that last one? Many of us were – and still are frankly (and I’ll write more on relapse prevention in research specifically another time). Now today we might add “a lack of connectedness” as one of those coping skills a client (that includes all family members remember) might be lacking. Professionally, we’ve done a pretty good job of helping clients to learn coping skills. Every rehab or treatment agency I know of has some group or class in coping skills training. But perhaps we’re missing something here. During a private conversation I had years ago with Dr. Marlatt, we discussed what might still be missing in relapse prevention as people in treatment typically have at least one recurrence of their old habit/behavior in their long-term recovery/change if not more. He said he believed it was likely this (paraphrasing due to my memory of the exact quote): “We’ve done a great job of teaching coping skills to folks. What we haven’t done such a great job of is helping folks learn how to pick up those skills when they need them.” In fact, at the time I recall we hypothesized that Motivational Interviewing might be a helpful bridge to this skill of picking up one’s coping skills v picking up the drug!
How about the physical side of relapse? Let’s look at cravings for drugs for a moment. In some ways, you can think of cravings for drugs as a symptom of distress and certainly of withdrawal from drugs (I’ll assume we can all relate to the feelings of sudden distress especially right now). Gorski calls these symptoms “Post-Acute Withdrawal Syndrome” or PAWS. I came to recognize this “constellation of symptoms,” as we call any group of symptoms, as basic symptoms of nearly all generalized distress/anxiety symptoms – and even as symptoms of trauma*:
- inability to think clearly
- memory problems
- emotional overreactions or numbness
- sleep disturbances
- physical coordination problems
- stress sensitivity
This makes sense since you could certainly think of detoxifying from any drug as a state of distress, and not just of the body but also of the mind and one’s world (bio-psycho-social). Hmm…
*To the other family members: you too have PAWS! We’ll talk more about your symptoms and recurring behaviors/habits as well as what you can do to ‘HHALLT’ your own less healthy behaviors and turn your reactions into responses.
So much of recovering one’s life – or building a new one – is about new behaviors, which is definitely where a lot of the distress comes from. The conversations we hear in our heads often goes like this: Can I make these changes? Will I ever have a life I can be proud of? Will I find work again? Will people find me boring/will I be bored? What will people think of me if they discover I’m a former drug addict (whatever term you’d like to use here)? Who will I be without drugs like alcohol? How will I ever have fun again? I remember saying all these things and more many, many times.
Right now we’re practicing social distancing which is completely necessary to protect us all. And at some point we’ll be back to our more usual social events though perhaps we’ll never be quite so nonchalant about things such as hugging strangers and even shaking hands will folks without quickly handwashing or using sanitizer. The world is likely to be different from here on which means the world for those of us recovering from problematic drug use is going to be too.
How exactly will this affect those of us in recovery? That remains to be seen. I had a brief call with a young client today who’s currently in rehab. He complained that they can’t attend 12 Step meetings right now which is what he knows he needs to stay away from using drugs: not necessarily the Steps but definitely being connected to others. And he’s not even a little bit interested in using video platforms. So, what will folks like him do? Hopefully not get a good case of the “fuckits” (we’ll discuss this more later in the series). Gratefully many of us in the professional world have been providing telephonic sessions or using video platforms to provide services and many of our clients are comfortable with the technology. But it is a change for many on ‘both sides of the couch’. I’ve found more clients willing to use these platforms at least for now. But for those professionals and our clients who can’t see a steady diet of using technology instead of live meetings of all kinds, we need to stay at home, go out only to get groceries or necessary products, and vow to make this as short and safe a “sheltering” as possible.
And if you, like my client, are already in treatment or a family member is, you all may be the lucky ones right now: there’s no cooking/food concerns; no wondering where you’ll sleep; no need to work right now; and you have people around you to connect with at any time. For others who are wondering how to keep their behavior change changed? We’re just going to have to adjust for now. For some folks that may mean not trying to stop or reduce their drug use right now. In those cases, I would suggest using “best practices” for whatever drug (including alcohol of course) you may be using (some online resources can be found in this footnote). There’s a lot of information to be found online and many of us professionals are offering free brief support services to provide a bit of information or listen/talk as needed to support someone in need. Some other ways to chill the distress? How about learning or practicing more regular meditation (which has been found to be beneficial with just 15 minutes of daily practice!)? Or how about taking a free course online? Try Coursera, The Great Courses Plus, or Open Culture for free University courses online. Or an exercise class? My daughter-in-law did an online dance class in LA recently and said several thousand people were online!! AA has always offered telephonic support (I did the overnight shift for several years once a month) and all support groups now have something available online (see the footnotes for some information to get you started). And finally, nutritional health is extremely important right now! (here’s a link to a recent study on nutrition and anxiety to get you started) And think of it this way? In an online class of any kind, you can be anyone you want and never have to say a word! There are benefits to being online – real anonymity!
Finally, if you can, reach out to others. There are still some ways to do this safely for many of us and helping others helps us feel connected and improves self-esteem. So if you’re healthy and able, consider working or volunteering to pick up meals or groceries for folks (check with your local food banks, shelters, Uber/Lyft, and more). Most of us can still go outside and walk which I’m encouraging all my clients who are able to do so. Walking around the block may not be quite as interesting as being at the seashore, or in the mountain trails or deserts but maybe you’ll find a new appreciation for your ‘hood: smell the flowers (yes, Spring has come in spite of COVID19), wave at neighbors (keep that 6’ distance of course) and check out your local businesses to support in some way, both now and later. Beauty is truly everywhere if we look for it.
So, stay safe and sane during this time and find novel ways to connect. Stay informed though take breaks from whatever news you watch/listen/read. Find an old friend to say hello to – or make some new ones online. Or just binge your favorite shows! My family and I are going to have a meal together this week via FaceTime: we’re going to cook in our separate kitchens and then sit down together to chat about what’s happening in our lives that isn’t virus connected. We’ve even considered picking a topic to help us stay on track of something interesting or fun and not just complaining! Whatever you do, do it with a splash of humor and lightness. We CAN do hard things and – this too will pass.
Stay tuned for Part 2: Relapse & Other Family Members & Part 3: Ch-Ch-Ch-Ch-Changes, coming soon!!
 Relapse Prevention, Second Edition: Maintenance Strategies in the Treatment of Addictive Behaviors 2nd Edition. Marlatt, GA & Donovan, DM. (2007). The Guilford Press.
 Motivational Interviewing, Third Edition: Helping People Change (2013). Miller & Rollnick. The Guilford Press.
This is just one link to an article on RP by Dr. Miller. https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1360-0443.91.12s1.6.x
 Borrowing from a 1980’s addiction treatment mnemonic, HALT, one of my RP groups & I lengthened HALT into HHALLT: Pay attention to these intense feelings: Hunger, Hurt, Anger, Loneliness, Lust, or being too Tired.
 These are just a few FREE online services: https://hams.cc/support/ support for abstinence, moderation, drugs including alcohol; https://erowid.org/ for info on psychedelics; www.moderation.org ; https://www.smartrecovery.org/; http://aa-intergroup.org/; https://anypositivechange.org/resources/ for resources on safer drug use. Also for anxiety/depression, check out my former TA/colleague Jeremy Prillwitz’ group at email@example.com .
 Here’s 2 studies but there are others: https://www.psypost.org/2019/06/study-15-minutes-of-meditation-associated-with-similar-effects-as-a-day-of-vacation-53798; https://www.psypost.org/2020/03/daily-meditation-decreases-anxiety-and-improves-cognitive-functioning-in-new-meditators-after-8-weeks-56198
 Here’s one resource for this information but there are many: https://umatter.princeton.edu/respect/tools/self-esteem