Relapse/Relapse Prevention: Part 3 of 3
“It is possible to make no mistakes and still lose. That’s called life.”
-Patrick Stewart as Capt. Jean-Luc Picard, Star Trek: The Next Generation
Change. Relapse. Much has been written about these phenomena and we certainly understand these processes better than we ever have. However, as much as we know, one thing keeps me up at night – both regarding my own desired changes and those of my clients – and that’s this phrase: “We don’t budget enough for change.” This was the first thing Dr. Alan Marlatt – researcher, psychologist, and mentor to many of us professionals in harm reduction and relapse prevention – taught me about relapse prevention and change. So what did he mean by this? He meant that we humans don’t expect change to be so darned difficult, so elusive; we expect change to be an event not a process and so we don’t plan on the spending the resources it will take to be successful in making a change, or to maintain that change. And it’s this thinking that gets us into A LOT of trouble.
A related phrase from Dr. Marlatt is “Seemingly Irrelevant Decisions,” or SIDs. Here’s an example of this concept:
“I decided to change my eating habits to see if I could improve the inflammation I’m having from areas of severe arthritis. I found a good nutritionist that I connected well with and we began our journey by looking at my current eating habits. One of the suggestions she made is that I reduce or eliminate added sugar in my diet and to help with this goal, she suggested I eliminate sugary products from the house to help me avoid temptation. Makes sense, I think, so I easily agree to do this. While at the store later that day, I spy a new gluten-free dessert (gluten-free is another part of my new eating plan). I say to myself, “Oh this could be really good and after all, it’s gluten-free. I really deserve something after all the changes I’m making. I’m sure this will be fine!” And I buy it, ignoring the sugar content and instead focus on the gluten-free aspect.”
See the SID? “It’ll be OK…I really deserve this…after all it’s gluten free.” Now I don’t want to suggest having a bit of sugar on occasion is wrong or bad. That’s up to me to decide, and a bit of sugar is actually OK for me to have (though it might not be for some). However, since I’m just beginning this new plan, it might be a good idea to stick as closely to my plan as possible until I get my “sea legs” under me, until this new way of eating becomes more of a regular habit.
This incident reminds me of the challenge with abstinence or any “perfect change” If I say that I’m never going to eat sugar again then I’m more likely to have a harder time challenging my “one time won’t hurt” statement in a couple of ways. If I were to change that perspective just a bit and instead start out by saying, “I’m going to cut down on sugar and eat it for special occasions only,” then I have more flexibility. I could then say I’m going to try this new dessert, but save it for a special occasion. Or I could eat part of that sugary thing, and stop myself by saying, “Oh jeez, I really didn’t want to do that. I can put it away and save it for another time like I said I would. I’ll just stop right now. No problem.” What does this accomplish? For one, I’m not catastrophizing that I ate some of the dessert. After all, It’s not like a little bit of sugar is absolutely going to lead to my eating a ton of sugar later. I know I can restart my less/sugar-free plan immediately. Also, I don’t feel like I’ve broken my vow of abstinence, something Dr. Marlatt called the Abstinence Violation Effect, or AVE. But if I don’t commit to abstinence, doesn’t that mean I’m allowing or choosing to make room for relapse? That’s what we’ve been taught, definitely. Let’s keep going and see.
The AVE concept is crucial to understanding relapse, something I’ve come to call the “fuckits”. You know, when you’re on a diet and someone offers you your favorite chocolate, so you eat a piece or two and then say, “F**k it. I already blew my diet so I might as well just keep going.” Dr. Marlatt liked to say, “Instead of continuing your drinking or other behavior, how about simply recommitting to your goal and stopping the behavior right there?” I remember thinking, “Really? What a concept! You can always begin again?” Well perhaps not if you’ve been taught that “once you have a drink or other drug, your addiction – that sleeping tiger – is awakened, and all hell will follow.” This is the problem with that sleeping tiger/disease model of addiction when it comes to relapse.
Ironically, those who believe in the disease concept of addiction are at higher risk of giving in to the “fuckits”. Dr. William Miller, co-author/developer of Motivational Interviewing, discusses this in an article titled, “What predicts relapse? Prospective testing of antecedent models”. In this study, Dr. Miller found two things were most predictive of relapse: 1) not having the ability to cope (i.e. lack of coping skills which I think makes sense) and 2) one’s belief in the disease model. Wow. That’s right: one’s belief in the disease model of addiction makes one more susceptible to relapse. Now I want to be clear here: just because many, like Drs. Marlatt and Miller and numerous others, don’t believe addiction is a disease (or at least it’s not for everyone) that doesn’t mean for a moment they don’t see addiction as a serious medical condition. We can also all agree that drug use changes one’s brain chemistry. I mean, that’s the point: I drank and used a ton of drugs for 20 years (from 12 to 31 years old) because for most of those years, drugs worked to positively change my brain chemistry! And this leads to the challenge for many folks with the argument against a disease concept of addiction: when they hear us say we don’t believe addiction is a disease, they hear that we must therefore believe it isn’t a medical problem or that drugs don’t change our brains. Nothing is further from the truth.
We simply mean that addiction is not a disease, not a medical condition only. But it’s definitely a chronic illness – and one that needs to viewed holistically (we’ll return to the concepts of ‘disease v. learning states or other possibilities’ and what good rehab should provide in a future blog as there’s much to say here. What’s important for this blog is that thinking of addiction as a lifelong, never-ending, permanent diseased brain state predicts relapse). At this point, I’d like to add a disease to our discussion that is purely medical: COVID-19 or the novel coronavirus. This is an important part of our conversation on relapse since we’ve seen a spike in overdoses and drug use in general, especially alcohol. And even if you’re not drinking or using other drugs during this time of sheltering, financial crisis, and protests/renewed awareness around racial inequalities, you’re being affected by our collective drug use and distress. I know I am.
I’ve been having a rough time recently with feeling incompetent as an addiction/health counselor, a bit burned out, just like I think we all are in some way these days. When this happens (which it does occasionally even when there isn’t COVID-19 etc. to concern me) I usually reach out to friends and/or colleagues to talk about what I’m feeling. So that’s what I did: I called a friend earlier today who’s a therapist as well as a longtime friend and we wound up talking about the concept of ‘”deprivation” or giving something up, like alcohol or other drugs. We discussed how humans don’t respond well to “deprivation” like we’re currently going through – and being worried we will be even more deprived soon is making this time even more stressful. What we respond better to is a “warm turkey” approach to change in our lives. Another way of looking at this is we respond better to adding something to our lives rather than looking at what we’re giving up. That’s why harm reduction strategies can be so helpful in so many different areas of our lives. Instead of “giving up,” one thing harm reduction suggests is that we NOT look at what we have to give up. Instead we suggest that folks change perspective and use strategies that help see change as something we’re moving towards (such as our values or goals in life) rather than what we’re walking away from (drug use, etc.) This is generally a more helpful point of view.
This leads to another set of important questions to ask yourself when you or a loved one goes to make a change in life that may also help you avoid a return to that behavior: “How do you typically make changes successfully in your life?” Looking at our successes helps build motivation to try again as well as giving us a possible starting point for a new change. One of my favorite sayings is this: “Success breeds success and failure breeds failure.” That means that we need to focus more on when someone does not use a drug, eat less nutritious food, does exercise, whatever. We should be asking, “What/how did you manage to do that?”
Clients are always shocked when I ask them that. And they usually struggle to answer by the way by saying, “I don’t know” or “Why?” It seems that this is due to our culture’s preoccupation on highlighting when things go wrong, when we make less healthy decisions, “tough self-love,” if you will. I’m not suggesting we should never look at these issues, but I am saying that if what we’re trying to do is help motivate someone we love including ourselves, we need to first look at successes. So, what can we friends/other family members/concerned others trying to help do? “Catch” our loved ones doing well.
This concept is straight from Solution Focused Brief Therapy (SFBT). Having been trained in SFBT in the early 2000’s really helped me change my focus with clients who had recently “relapsed.” Prior to this time, I was taught to focus on the negative actions and particularly on the “problem” thought processes that led to a client returning to the old behavior.¹ Again, while there’s a time for reviewing when things started to go wrong, doing this before someone is emotional stable is typically retraumatizing and distressing – and too often leads to more drug use (or other behaviors) and not less.
Community Reinforcement Approach and Family Training (CRAFT), in which I was trained in the late 2000’s by its developer Dr. Robert Meyers, also uses this idea of our focus being “catch your loved one doing what you want them to do” instead of the old, less positive behavior. Here’s an example:
Back to my example of changing my eating habits. So, my family is trying to support me in these changes that I’m struggling with. Which seems more supportive & motivating? 1) my son saying, “Mom what are you eating? Don’t you remember how sick that makes you feel? Does the doctor say it’s OK to eat that?” or 2) my son saying, “You know mom it’s so great that you’re making these changes and I know it’s hard. I’d love to cook a meal for you that includes things you’ve seen are better for you to eat. What could I make for you that’s healthy for you?” or even 3) my son says, “Mom, I’ve noticed how much more fun it is to be around you since you started eating on this new food plan! You seem in less pain and you have more energy to do things.” Hear the difference? Or how about my son saying, “You look like you’re not feeling well tonight Mom. We could just watch a movie here instead of trying to go out this time if you prefer.”
Let me give you an example regarding drug use:
Your daughter has been using opiates for a while and you’re really scared that she’s developed an unhealthy attachment to them. You’re also frustrated that too often when you see her lately, she appears ‘out of it’ and unable to participate in whatever plans you all have made. Instead of confronting her when she’s under the influence, CRAFT suggests you wait until she’s less or not intoxicated to have a reasonable conversation with her (no drama please!) If that’s not possible, then saying something like, “You know sweetheart we all love it when you’re able to play cards with us on Friday nights. And we all agreed that when we play cards, we’d all be abstinent. I can see that tonight you’ve not been able to abstain and I understand. We’re sorry that you’re not able to play tonight, but let’s try another night over the weekend, OK?” You’ve confronted the behavior you don’t want and highlighted the behavior you do want. Another possible response would be to say, “I see you’ve been using today and you’re not feeling like yourself/well. What if we just watch a movie together tonight and save cards for another time when we can all abstain? Would you like to spend some time with us, or is that too much right now?” Can you see yourself saying something like this to your loved one using drugs problematically, rather than suggesting you can’t be around them when they’re under the influence? Is it possible?
“Do. Or do not. There is no try.”
-Yoda, Star Wars: The Empire Strikes Back
Bottom line: change is hard. And boy, is that an understatement! We are seeing that played out everywhere in our world right now. And there are no short cuts, no “express elevator” to change. Only hard work and baby steps of the “two forward, three back, four forward, one back” kind for most of us. And that’s OK. As long as we stay on the spirally road of change we have the possibility of something actually changing. I can absolutely guarantee that no change will happen if you quit trying. In other words, Yoda was wrong! Trying is what we MUST do, constantly, no matter what. The average times someone tries to quit smoking – called the most addictive substance in the world by some – is 30!!! Can you imagine after the 25th round of drug rehab someone says, “It’s OK, it takes what it takes. Just keep trying!” Ha.
Sadly, our culture implies that we should only need one, perhaps two, treatment episodes to be abstinent, the only “allowed” goal of nearly all our drug treatment in the US. And yet, we also say “this is a chronic relapsing disease”. Well, guess what? You can’t have it both ways. So what’ll it be?
Of course, this also implies that we need affordable as well as effective drug treatment. But perhaps what we need even more is an early form of help, a way to support people making changes that they want to make, in a way that makes sense to them, and that might even feel positive. Dr. Marlatt also used to say that (paraphrasing here) “We need to make recovery as enticing and helpful as drug use – and if we can’t, we need to admit that. At least be honest.” I wonder what would’ve been different for so many of the thousands of folks I’ve worked with over the years if we simply managed to do that and stop pretending that drugs are all bad. After all, if they’re that bad, why did I (or anyone else) continue to use them for two decades? We’re not stupid, and I wasn’t physically dependent on them for many years so it can’t be just that. We must look at change and especially addiction and change much differently – and we CERTAINLY have to look at drugs differently.
Well, that’s it for me for now. I’ll be with you again sometime in September for Recovery Month to discuss more about the words recovery, relapse, and others. In fact, I’ll be giving you a list of words to be wary of when you hear them coming out of the mouths of professionals, especially rehabs. For now, let me leave you with this: what if we decided the word recovery meant simply change, and not abstinence (such as my own phrase, Harm Reduction Recovery™)? What might drug treatment look like if we did just that?
In the meantime, please join us Friday, August 14, 2020 at 5pm EDT for Responding to an Opioid Overdose at Home as part of our preparations for National Overdose Awareness Day, August 31, 2020.
And get ready for the publication of our online eBook coming in September in honor of Recovery Month! This eBook is a collection of my blogs for FSDP over the past two years as well as some added musings from a few Friends of FSDP we know you’ll enjoy. All proceeds will go to FSDP to continue their support of sensible drug policies and related efforts. Thanks in advance! See you in September!!
Be well, be safe, and be kind.
Author, Coming to Harm Reduction Kicking and Screaming: Looking for Harm Reduction in a 12-Step World
To contact me, go to www.deedeestoutconsulting.com
¹Terence Gorksi’s method of relapse prevention is highly based in CBT. His method/curriculum is also the primary theory used in traditional rehab. I studied with Mr. Gorski in the mid-90’s but it was Dr. Alan Marlatt that ultimately helped me shift my work and thinking in this area along with Chicago’s Dr. Scott D. Miller who had studied with the developers of SFBT.
²For more specific information, here’s one reliable source with criticisms: https://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories6.html