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Overview of Substance Related Disorders

The Substance-Related Disorders include disorders related to the taking of a drug of abuse (including alcohol), to the side effects of a medication, and to toxin exposure.  The term substance can refer to either a drug of abuse, medication, or toxin.  The substances are grouped into eleven classes:

SA Relapse

 

Each class is unique but also shares features with other classes.   For example, alcohol shares features with the sedatives, hypnotics, and anxiolytics.  Also, cocaine shares features with amphetamines or similarly acting sympathomimetics.  Many prescribed and over-the-counter medications can also cause Substance-Related Disorders.  Symptoms generally occur at high doses of the medication and usually disappear when the dosage is lowered or the medication is stopped.  Medications that may cause Substance-Related Disorders include, but are not limited to, anesthetics and analgesics, anti-cholinergic agents, anticonvulsants, antihistamines, antihypertensive and cardiovascular medications, antimicrobial medications, anti-parkinsonian medications, chemotherapeutic agents, corticosteroids, gastrointestinal medications, muscle relaxants, non-steroidal anti-inflammatory medications, other over-the-counter medications, antidepressant medications, and disulfiram.

Exposure to a wide range of other chemical substances can also lead to the development of a Substance-Related Disorder.  Toxic substances that may cause Substances-Related Disorders include, but are not limited to, heavy metals (e.g., lead or aluminum), poisons containing strychnine, pesticides containing nicotine, or acetylcholinesterase inhibitors, nerve gases, ethylene glycol (antifreeze), carbon monoxide, and carbon dioxide.  The volatile substances (e.g., fuel, paint) are classified as inhalants if they are used for the purpose of becoming intoxicated; they are generally considered toxins if exposure is accidental or part of intentional poisoning.  Impairments in cognition or mood are the most common symptoms associated with toxic substances, although anxiety, hallucinations, delusions or seizures can also result.  Symptoms usually disappear when the individual is no longer exposed to the substance, but resolution of symptoms can take weeks or months and may require treatment.

The Substance-Related Disorders are divided into two groups: the Substance Use Disorders (Substance Dependence and Substance Abuse) and the Substance-Induced Disorders (Substance Intoxication, Substance Withdrawal, Substance-Induced Delirium, Substance-Induced Persisting Dementia,  Substance Persisting Amestic Disorder, Substance-Induced Psychotic Disorder, Substance-Induced Mood Disorder, and Substance-Induced Anxiety disorder, Substance-Induced Sexual Dysfunction, and Substance-Induced Sleep Disorder).     

The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. It should be noted that unsuccessful attempts to stop using yields the relapse element of the Disease of Addiction model.   There is also a pattern of repeated self-administration that can result in tolerance, withdrawal, relapse, and compulsive drug-taking behavior.   Substance Dependence can result from every class of substances (except caffeine).  The symptoms of dependence are similar across the various categories  of substances, but for certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not generally specified for Hallucinogen Dependence).  Craving (a strong subjective drive to use the substance) is likely to be experienced by most if not all individuals with dependence.  Craving is also a key element in the relapse process. 

The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.  To be classified as abuse, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent.  Also, there may be repeated failure to fulfill major role obligations, repeated use in a situation in which it is physically hazardous (driving under the influence), multiple legal problems, and recurrent social and interpersonal problems.   A binge drinker is a prime example of a person who abuses alcohol.  This individual generally does not drink on a regular basis but has a tendency to become intoxicated when he does drink.  Also, they generally demonstrate impaired judgment, poor decision making ability and engage in high-risk behaviors.  This sequence of events generally leads to multiple family, social, and legal problems. 

 

Relapse Introduction   recovery

In general, relapse is a return to former problematic use of alcohol and/or other drugs or it may also be considered a breakdown of the addiction recovery process.  The world of substance abuse/addiction is difficult to understand and overcome. For example, an individual may abstain for several months and then return to use.  During their time of abstinence, some individuals process negative thoughts and yield to negative pressures; some say its like having a large weight over their head that increases each day and eventually something will trigger their return to use.  Another example of problematic use (that does not fit into the classical definition of relapse) is a binge drinker who is prone to get into trouble almost every time they drink.  He or she is one who may not drink on a regular basis but when they do drink they drink to excess and generally get into legal trouble (DUI, public intoxication, spouse abuse, etc); consequently, this extends the definition of relapse to include habitual problem drinkers/users.  The multiple defender programs are full of people who are not alcoholics but rather are problematic users in that they cant control how much they drink and are unable to avoid high-risk activities after they start to drink.  It follows that their only treatment option is total abstinence.

It should be recognized for an individual who is susceptible to alcoholism/addiction; relapse can be a life or death consequence.  As a few drinks or one episode of drug use can lead to resumption of excessive drinking/using very quickly.  Individuals who relapse are at a higher risk of accidents, overdose, and/or medical problems as well as increased family, work and social problems.

Early work with problem uses viewed relapse with a strong negative bias and attempts at counseling the offender generally resulted in additional guilt heaped onto an already burdened individual; consequently, the counseling outcomes were generally negative.  Relapse is now accepted as one aspect of the disease of addiction (disease concept contains a chronic relapsing disorder element).   As noted previously, in early addictions work relapse was considered one act of use.  At present, it is considered a return to a substance controlled way of life.

Professionals tend to look at relapse as a process that revolves around ones thought processes.  For example, if one is thinking positive they are involved in activities such as responsible living, healthy social activities, and are constantly self monitoring their activities and choices to ensure they stay on track to minimize the risk of relapse.   Whereas, with negative thinking, one is prone to deny their problem, avoid support groups, stop treatment programs and often dwell on past behaviors (euphoric recall or remembering how good the alcohol and other drugs make them feel).   The latter idea is also based on the concept that an idle mind often wanders in the wrong direction.

The key to relapse is avoidance of out-of-control situations that constitute a high risk situation for that individual.  The major philosophical approaches to relapse are:

  •         Unmanageable feelings and emotions:  The emotional state of an individual in recovery can be like a roller coaster with extreme high and lows.  The individual may react to either bad feelings (anger, grief, jealousy, hate, loneliness, boredom, depression and many others) or good feelings `(happiness, euphoria, exalted self confidence) and either can trigger a return to use.
  •         Environmental situations:  When we visit a former using friend or place it brings back strong emotions that are difficult to control.  Also, the brain recalls the pleasure associated with the former use.   The brain also has a tendency to deny the unpleasant consequences of the former use.
  •         Poor personal management:  Sobriety brings a new set of conditions and we often are lost for what to do and when; consequently, if we dont plan and prioritize our new way of life, then we are at risk of falling back into our old patterns and routines.  

 

 Ambox_warning_psycho  Relapse Triggers and High Risk Situations

Any activity that threatens an individuals abstinence or their ability to control their emotions is considered high-risk. This includes people, places and circumstances that were previously associated with use, as well as any behavior that increases the probability of use.  Cummings, Gordon, and Marlatt (1980) found that negative emotional states such as anger, frustration and boredom account for 35% of all relapses; interpersonal conflicts account for about 16%; and social pressure account for 20%.

Triggers are generally sensory based; they cause an immediate reaction in a person and create an urge to use.  Triggers for an alcoholic might include non-alcoholic beer, cigarettes or meeting a former drinking buddy.  Triggers for a cocaine (white powdery substance) addict might include flour, a razor blade, straws, or going to a place where he/she formerly used.

A relapse trigger that is often overlooked or under estimated is the ritual that a user followed during his/her earlier use.  Addicts have explained their ritual as like being on automatic pilot where the urge or anticipation of use masks conscious awareness of what is occurring.  Rituals are somewhat related to preoccupation (preoccupation is a thought without behavior, whereas a ritual is a behavior without thoughts); consequently, a ritual can be defined as a set of habits which are automatic and key automatic responses within an individual.  It follows that ritualistic use of a mind-altering chemical substance is a procedure repeated customarily or automatically and needs to be evaluated for its potential to trigger a high risk situation.  This may be any event or process that a person followed consistently during pre-treatment chemical use.  It can be as simple as driving on a street where a former dealer lived or stashing or allocating money for a specific purpose.  Most people follow a ritual of using but some may not be conscious of their process.  For example, the concept of Thank God its Friday is part of the overall using environment; consequently, it may be part of an individuals ritual and may initiate use at a particular place or time (Friday after work at Joes bar).

 

Relapse Symptoms

It is important for the recovering individual to be aware of high risk situations that could trigger a relapse.  It is equally important for them to be aware of symptoms that often precede a relapse.  Denial is also a critical issue with relapse.  Just as addicts will not admit that they have a problem, a recovering addict will often deny the impulses, urges and cravings to use again after being drug free for a period of time.  It is also possible that the client may not be fully aware of what he/she is feeling, but that he/she may recognize certain symptoms that could serve as warning signs for a possible relapse.  Specifically, for alcohol dependency, relapse is the choice to drink after being clean and sober for a time. It helps though to view relapse as a process that begins well in advance of that act. People who have relapsed can usually point back to certain things that they thought about and did long before they actually drank or used that eventually caused the relapse. They may have become complacent in their program of recovery in some way or refused to ask for help when they needed it. Each individuals relapse factors, diagnosis, treatment, and recovery plan are unique to them.  Relapse is generally the result of a combination of factors. Some possible factors and warning signs might be:

  •         Involvement  with former drinking/using associates (why me attitude; they can drink why cant I)
  •         Maintaining an easily accessible supply
  •         Drop out of treatment; stop going to support meetings
  •         Obsession with former life style (dreams, flashbacks and other delusions)
  •         Over confident (think you are strong enough to overcome addiction without help)
  •         Family, work and legal conflicts
  •         Flawed or unrealistic goals; Intolerant–expect perfection in self and others
  •         Dislike for self; boredom
  •         Eating disorder; personal hygiene issues
  •         High stress level in home, community, and work environments
  •         Failure to turn lose of past conflicts
  •          Obsessive behaviors unable to relax
  •         Crises in home, work or other relationships
  •         Lack of Spirituality; drop out of church

 

Almost everyone in recovery has times when compelling thoughts of drinking or using drugs resurface. In early recovery, drinking or drugging dreams are not uncommon. It helps if the the individual can be reminded that the reality of drinking and using has caused many problems in their life. That no matter how bad things get, the benefits of staying abstinent will far outweigh any short term relief that might be found in drugs or alcohol use.  Also they need to program themselves to recognize that recovery takes time.  A visualization that can be used is to represent the brain as the face of a clock with the hand of the clock pointing to 12:00 o’clock (represents normal state of brain prior to alcohol/drug use).  The visualize a brain of an addicted individual with about a 30 degree offset (hand points to 1:00 pm) and that offset represent the chemical changes in the brain due to drugs and/or alcohol use/abuse.  In other words, the brain has been programmed to be comfortable in an altered state due to the substances that have been used.  Over time and with total abstinence, the brain will return to normal.  For some, (depending on how long and how much they have used) the recovery is relatively quick whereas  for others it can take years but eventually their brain will return to normal.  Their bodies (including their brain) were created with an ability to restore itself; consequently, the cravings, dreams, and uncertainties of early recovery will eventually fade.  An exercise that can be helpful for clients is for them to perform what can be called a Return-On-Investment (ROI) assessment.  This assessment is fairly simple and requires the individual to document the perceived gains (feel good, relaxation, and increased social skills) versus the losses (legal problems, health issues, financial drain, family problems) and then weigh the advantages versus the disadvantages.  Then ask the client to dollarize or value the outcomes and to determine if drinking and/or using is a good investment.  In most cases the individual will agree that whatever they invested into drinking and using other drugs is a negative ROI.   For example, when a smoking ROI assessment is performed the conclusion is that it is totally a negative return on investment (financial, health, social).  This exercise is more on the logical side, for them to see the big picture.  Please note this will not change their behavior alone in most cases. 

Another complicating factor in relapse prevention is the combination of a psychiatric disorder and a substance related disorder.   This is commonly referred to as a dual disorder and makes the treatment regimes and relapse prevention efforts more complex (they generally need to be addressed simultaneously).  Obviously, the risk of Relapse increases dramatically with the dual disorder as either the substance-related disorder or the psychological disorder may trigger a return to use.  For example, psychological factors such as grief, joy, and sadness that may be totally isolated from alcohol and other drug use but may trigger a substance-related relapse (this is often referred to as the domino effect).   Drinking and drugging can also lead to a flare-up of a psychiatric illness and can also change the effects of psychiatric medications with unpredictable results. Maintaining abstinence allows the person the freedom to grow as an individual and manage the illnesses in the healthiest possible way.

Individuals in dual recovery key on a unique set of warning signs that they are aware of and that they must be concerned with.  They learn the importance of early identification and appropriate actions to prevent a full blown relapse.  They generally follow a practical plan that addresses their emotional or psychiatric illness in a positive and constructive way. The quicker they learn to spot these signs the sooner they can take positive action for their own well-being and dual recovery. When we are committed to dual recovery we slowly but surely develop a new confidence in our new way of life without drugs and alcohol. It follows that abstinence and dealing positively with a dual disorder go hand in hand. Individuals build a personal inventory of recovery tools that help them meet these goals by staying involved in the process of dual recovery.  People in dual recovery also make sure to use some of their recovery tools each and every day. Their personal recovery tool kit serves as the best protection against a relapse.

As noted previously, the process of relapse generally begins well in advance of the initial use. Individuals can usually point to certain emotions or thoughts that they processed long before they actually drank or used. They may also have become complacent in their program of recovery in some way or refused to ask for help when they needed it.   Relapse is usually preceded by a combination of factors. Some possible factors and warning signs might be:

  •         Stop taking prescribed medications (not finishing the prescription after beginning to feel better);
  •          Peer pressure; visiting and hanging out with former using associates;
  •          Isolation; withdrawal from family and other social functions; Introverted
  •          Maintaining a supply of alcohol and/or other drugs;
  •          Irrational/obsessive  thinking about prior use (how good it was); blaming other problems for alcohol/drug use;
  •          Stop treatment/therapy;
  •          Overconfident feel like you can whip this problem all by yourself;
  •          Family conflicts; using spouse;
  •          Poor personal management skills perfectionism;
  •          Poor eating and sleeping habits, or personal hygiene;
  •          Stress (often self imposed)
  •          Boredom irritability lack of routine and structure in life;
  •          Changes in psychiatric symptoms; extreme emotional swings;
  •          Anger/ unresolved conflicts;
  •          Involvement in high risk activities (obsessive behaviors workaholic gambling selfishness);
  •          Significant changes loss grief trauma painful emotions.

 

Ignoring Relapse Warning Signs and Triggers stinkin

Compelling thoughts regarding a return to former drinking and/or using habits is an integral part of the relapse process. It helps to remember the consequences of drinking and using have resulted in complex negativities in their lives.   It is often difficult to convince a client who is suffering that recovery takes time and that the dedicated effort will be rewarded. Eventually the urge to return to use will fade and the individual will slowly but surely develop a new confidence in his or her new way of life.  However, we must recognize that staying clean and sober requires a commitment on a daily basis.  An individual in recovery must follow a regime that focuses on the recovery needs for both illnesses. People in dual recovery generally use their recovery tools (coping strategies) daily.  By constructive management of their lives and by being proactive in their treatment program they can minimum the risk of relapse.  The individual should periodically review their relapse prevention plans with their doctors, treatment professionals and sponsors and modify them as needed.  In summary, the factors of the minimization of the risk of relapse by becoming familiar with the triggers and warning signs, utilizing the various recovery tools, and having a practical plan of action in the event a strong urge to use is experienced are all important. If and when lapses do happen, do not judge or blame. The person in recovery seeks progress not perfection. They simply learn what they can from the situation and move on with their program of recovery. Sharing this relapse experience with their sponsor, group, and helping professionals is an important way to figure out what went wrong. Their experience may also help others in recovery.

 

Relapse Prevention

A comprehensive relapse prevention technique has been described by Marlatt and Gordon (1995).  They suggested an approach where high risk situations were assessed and then coping strategies were developed for each situation.  The following factors were analyzed for each situation:

  •       Self efficacy: individuals perception of his/her ability to cope with a situation.
  •         Expectation: what is the consequence to the user of a specific behavior?
  •        Attribute: why an individual exhibits a specific behavior.
  •         Decision making: methodology used when the individual chooses a specific action.

 

Once this analysis is complete, Marlatt and Gordon (1985) suggest the following intervention strategies:

      

           Self-monitoring: Means to pay attention to a thought, feeling, behavior or social interaction. The following tools will help with this task:

o       Anticipation:  Anticipate experiences that could tempt you to revert to the former behavior along with  resumption of use of alcohol;

o       Preparation:  Prepare to employ a positive  alternative in lieu of the former self-defeating negative behavior;

o       Constant Awareness:  Increases the appreciation of the alternative lifestyle (applications are used as positive reinforcement and gain favor over time);

o       Management: One of the most effective methods is to maintain a log of substances used and/or urges to use.  Information such as intensity of urge, what triggered the urge, and coping strategy should also be documented.

o       Direct Observation: individual rates the degree of temptation due to high-risk situations.  The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters.

        Coping Skills: this analytical tool is used to document the clients ability to cope once a trigger or high risk behavior is encountered.  This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement.

        Decision Matrix: the matrix is used to document the consequences of a specific decision or action.  It may be used to gather immediate, as well as delayed consequences and can document both positive and negative outcomes.

        Behavior Commitment: this tool is intended to establish limits on use in the event of a slip.  It is also a commitment to seek help at the first indication of use to prevent a full-scale relapse.

         Reminder Flags – they are used to key specific action in the event of strong urge.

It follows that a primary goal of any relapse prevention program is to enable the individual to cope with future, inevitable urges to use.  The initial step is to identify the coping strategies that can be used in high risk situations.  It is also important to discuss an implementation plan for how these skills will be used.  Some have referred to this process as setting up a self-management program.  According to Ricky George (1990), The goals of self-management programs are to teach the individual how to anticipate and cope with the problem of relapse.  This approach generally combines behavioral skills training, cognitive interventions and lifestyle changes to help the individual modify their behavior.

The most frequently applied relapse prevention method is the cognitive-behavioral approach.  The primary feature of this approach is that it acknowledges the individual may have had little or no control over becoming addicted (disease concept) but has total responsibility for management of his/her recovery AATBS (1992).

 

Recovery Model

This model is based on the concept that recovery is a process that requires the mastery of emotional, psychological, social and recovery related tasks.  These tasks, which become increasingly more challenging, are the foundation for recovery.  Recovery is defined as the ongoing process of improving ones level of functioning while striving to maintain abstinence (avoiding relapse) from mood-altering chemicals.  A brief overview of the recovery process follows (NAADAC Desk Reference and Study Guide on Addiction Counseling (1996)):

 

Pre-treatment phase – the individual experiences or becomes aware of:

  •         Unpleasant consequences of use and abuse of mind-altering substances (legal, family, loss of freedom, etc.).
  •        Loss of control of their life due to their use.
  •         Emotional pain (may motivate individual to decide to enter treatment).

 

Initial stabilization:

  •         Stop use of mood-altering substance(s).
  •         Medical managed withdrawal (minimizes risk of medical complications during withdrawal).
  •         Help with controlling impulsive behavior.

 

Phase 1 Recovery (Getting Started):

  •         Helps individual to accept and comprehend the addiction process.
  •         Identify use triggers – develop plan to avoid and control impulses.
  •         Learn problem solving, stress management and anger management skills.
  •         Accept personal responsibility for self (choices, decisions and behaviors).
  •         Express feelings.
  •         Introduction to self-help groups.

 

Phase 2 Recovery (Early):

  •       Accepts need for recovery.
  •       Accepts responsibility for management of use.
  •       Begins to develop a clean and sober image.
  •       Acknowledges the need for lifestyle changes.
  •       Adjusts to drug-free behavior – apply new problem solving skills as needed.
  •       May struggle with peer and family issues as drug-free lifestyle is demonstrated.
  •        Improved self-image.

 

Phase 3 (Middle):

  •         Changed behavior aligned with new self-concept.
  •         Accepts responsibility for own recovery.
  •         Recognizes and embraces success of recovery.
  •         Incorporate problem solving skills into new lifestyle.
  •         Comfortable with lifestyle changes.
  •         Continues to struggle with peer and family issues.
  •         Learns to balance and control life.

 

Phase 4 (Advanced):

  •       Focus on learning coping skills to help deal with peers and family and issues related to predated use.
  •       Increases scope of life; starts to fulfill potential.
  •       Develops balance and takes control of life.
  •       Develops independence from the treatment program – develops self initiative.
  •       Accepts identity as a recovering individual.

 

After Care:

        Positive experiences fuels personal growth.

        Focus on total person (activities, spiritual growth and independence).

 

Step One

Individuals frequently relapse because of a failure to recognize and fully understand Step One of the self help, 12 Steps established by Alcoholics Anonymous. Without an in-depth understanding of Step One of the self-help program, continuing recovery from alcoholism or drug dependency will not succeed.

STEP 1: “WE ADMITTED WE WERE POWERLESS OVER DRUGS AND ALCOHOL”

A thorough understanding of ones powerlessness must be solidly and firmly rooted or an individual may fail to arrest the progression of the disease.  Treatment and recovery are impossible until an individual accepts the seriousness of the illness.  It is very hard for gifted, talented, dynamic or successful outgoing people to recognize they have hit bottom.  Powerless does not mean helpless, because there are positive steps to take to make you get better.  Powerless does not mean you have no willpower.  Willpower cannot be strong enough to suppress the symptoms of a disease.  The symptoms of diarrhea, coughing, sneezing or vomiting cannot be controlled by willpower.  THE SYMPTOMS OF ALCOHOLISM OR DRUG DEPENDENCY LIKEWISE WILL PROGRESS IN SPITE OF WILLPOWER.  The need is not willpower; the need is a healing power.

Some patients in treatment do not understand powerlessness.  These patients who say, If I can discover the problem areas in my life, Ill be okay.  Other examples would be those who say My problem is my job, The economy is bad and the stresses at work is causing my alcohol or drug problems, I have emotional problems, not an alcohol or drug problem.  Those with an addiction who express these attitudes clearly do not have an understanding of STEP ONE.

 

When an individual has honestly taken the first step he/she will recognize the following truths about himself or herself on a daily basis:

1.    The individual will have given up trying to control (on their own) his/her alcohol or drug use.

2.    The individual will have given up the belief that he/she can learn to drink or use like other people.

3.    The individual will accept that he/she needs help from others, Professional or recovering alcoholics and addicts.

4.    The individual will know that he/she cannot use alcohol or other drugs with safety.  Relapse is a daily issue in early recovery regardless of how one feels or thinks.

5.    The individual will be willing to follow treatment recommendation for continued care or outpatient therapy after discharge.

6.    The individual will have a sponsor and home-group identified before leaving treatment.

 

Keys to Avoiding Relapse:  The following actions have proven effective to help reduce the risk of relapse:

  •         High Activity Level (an idle mind may process negative thoughts; likewise idle feet may wonder in the wrong direction);
  •         Generate and follow to do lists to prioritize and  guide daily activities);
  •          Goal setting / acknowledge and reward success;
  •         Individual reward system (work toward a specific, individualized reward (i.e., car, trip, clothes, etc.) ;
  •         Plan pleasurable activities, as well as work (hobbies, travel, read, etc.);
  •         Plan self improvement activities (items that will help the individual feel good about themselves);
  •         Exercise / active lifestyle;
  •         Nutrition program;
  •         Rest / relaxation time;
  •         Manage stress;
  •         Think positive;
  •         Avoidance of high risk situations / activities;  avoid places / events where previously used;
  •         Avoid social functions that have an AOD focus;
  •         Avoid things that have triggered previous relapses;
  •         Avoid former using buddies;
  •         Develop mind-management techniques – Block negative thought processes.  The mind always leads the physical act (i.e. an individual thinks positive regarding an activity before they do the activity): consequently, if we could train our minds to detect wrong thinking (about use and abuse of AOD) then we could alter or disrupt those thoughts and focus on different things or thought processes to avoid actually relapsing;
  •         Avoid over confident feeling like I am in control and I have this AOD problem licked – generally, overconfidence leads to high risk behavior and poor decision making;
  •         Avoid out-of-balance emotional states.  Either feeling too good (overconfident) or too bad (depression) can lead to resumption of use;
  •         Forgetting or rationalizing away the pain and anguish of the former lifestyle.  Our minds will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences.  At times, individuals are convinced that returning to use would be wonderful (taste, feeling, emotions, etc.) And when they actually use they become deeply depressed as the reality of their actual use is realized.  The mind is a wonderful thing, but it too must be monitored and trained and one must realize that the mind can be misleading in some cases;
  •         Think positive; act positive; surround yourself with positive people – remember the little engine that said I can.

Finally: The individual should know themselves and be true to themselves and avoid situations that they are not comfortable with and are not capable of handling at this stage of the recovery.  They need to remember that they are responsible for the management of their recovery.

 

Depression1Relapse Cycle: Major Events/Emotional Reactions

As one walks the road of recovery they often encounter pitfalls and obstacles.  The following are a few of my personal observations (based on actual counseling experiences):

Early Recovery:  Individuals were excited about working their program and it helped them to feel better. It helped them to deal with problems, gain control of their lives, and cope with situations that had been previously problematic.  In essence, it helped them to cope in an alcohol/drug free environment.  Their social skills were improved especially in non-drinking situations.

Problematic Situations:  Over time they began to encounter situations in recovery that were very difficult for them to cope with.  Also, they had difficulty motivating themselves to solve problems in a sober and responsible manner.  They began to process negative thought about the recovery program, and to doubt their ability to maintain a clean and sober lifestyle.  They also began to self-medicate with alcohol and/or other drugs.   In essence, they lacked the drive and motivation to maintain an effective recovery program.  Also, they reverted back to their old ways of thinking, managing feelings, and behaving that make them look good on the outside but left them feeling bad on the inside.  They also hid or masked their bad feelings from family and friends.

Reactions to High-Stress:  During the tension building phase, they started to react to stress more emotionally than before and they began to isolate themselves from others in their support group.  Their stress level increased to where it was difficult to deal with even routine situations.  They were quick to anger and blamed others for all of the ills in their life.  Their mood swings became extreme and they were out-of- control most of the time. 

Denial:  They quit on their recovery program.  They stopped doing the things that helped them become clean and sober.  They became overconfident and started thinking they was cured.  They became bored with all that treatment/recovery routine.  They became more introverted and stopped telling others of their struggles.  They denied their slippery situation and tried to convince themselves that everything was okay although they knew it ‘.  They debated between sobriety and their addictive self and sometimes make poor choices although they knew better.  Straddling the fence is a very precarious and unstable position!

Belief/Value System:   Their old, self-defeating belief and value system comes to life when they encounter stress and other challenges associated with their recovery program.  They begin to believe that they are cured and that they can use alcohol and/or other drugs in moderation.  They began to believe that they no longer need to work a recovery program or that that they need a support group.  They mistakenly believe that nothing bad would happen if they drank only in social settings and limited themselves to only recreational drug use.  Their perceptions or insights about themselves and their recovery became much distorted.

Distorted Thinking:      These self-defeating thought processes begin showing in what they think and what they say to others.  They justify relapse and convince themselves that its okay if they decide to use alcohol and/or other drugs.  They also attempt to convince themselves that they have no choice but to yield to self-defeating behaviors. 

Urges to Use: They started to feel deprived, anxious and bored in their recovery.  They also experienced strong desires (cravings) to use again as their mind continued to focus on how good the former use was and imaging how good things would be in the future if they started using again.

Social Isolation:  They justified to themselves that it’s okay to avoid individuals and activities that are targeted to help them stay sober.  They stopped attending support groups and stopped professional counseling.  They started associating with people, places and things that support their addictive nature and make it easy for them to get or use alcohol and/or other drugs.

Crisis/Irrational Behaviors:   They began having irrational thoughts and problems that were troublesome.  As they attempt to solve the problems, new problems arrived before the old ones are completely resolved.  They struggle to see the big picture, feel depressed and try to distract themselves by doing things that won’t help.  Things keep going wrong, and they feel like nothing is going their way.   They think using alcohol and other drugs will make them feel better and solve their problems.  They try to put the thoughts out of their mind, but sometimes they’re so strong they can’t stop processing them.  They start to believe that relapsing is the only way to keep from going crazy.  Relapsing actually looks like a sane and rational alternative.  This is a true picture of an individual on a slippery slope heading for a total relapse.

Unmanageability:    They are overwhelmed by and caught up in an endless stream of unmanageable problems.  Their energy is exhausted and they feel like giving up. They have difficulty in focusing on important matters and they are unable to commit themselves sufficiently to complete a difficult task.  They also have a tendency to exaggerate small problems.  They begin to feel depressed and struggle with self-confidence.

Resumption of Addictive Thinking: They start to process flawed thoughts that violate their own values/belief system.  As a result, they start losing respect for themselves and start to hurt those around them.  Their involvement in treatment and self-help groups begin to diminish.  Isolation increases and they cut themselves off from others by ignoring them.   They begin the why me/self-pity behavioral pattern to get attention.  Guilt and shame are their constant companions.  They know they’re out of control, but keep making excuses for their behavior.  They begin to focus on a return to use as a way to salvage their sanity.

High-Risk Situations:  They begin to process thoughts about how good it was to drink and use other drugs.   They also convinced themselves that they could drink alcohol or use other drugs in moderation; however, deep inside they know that they can’t.   Involvement with high-risk situations became a part of their life.  They also began to surround themselves with people who are using and encouraging them to use.  They know there are on a slippery slope and that they are almost ready to take the plunge (total relapse).

Relapse:  Return to use appears to be a viable solution to their problem; however, deep inside they know that resumption will bring only temporary relief and will bring a new set of issues that have to be dealt with.  They resume use and try to control the amount they use.  They are disappointed because the relapse isn’t doing for them what they thought it would.  Very quickly their use is out of control and is causing severe problems in their life and health.  The problems continue to get worse until they again, realize that they need help and decide to try recovery one more time.  The cycle continues.

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Relapse Prevention Summary

Each client should develop a relapse prevention plan that includes specific coping strategies for each relapse triggers. The following types of information should be included although each plan will be unique and tailored to specific circumstances surrounding that individual.

 

These are recommendations you can give to clients in recovery:

  •         Maintain a contact list and involve others in your recovery
  •         Identify and prioritize triggers (those that have caused an earlier lapse or relapse)
  •         Identify specific coping strategies for each potential relapse trigger
  •         Identify people, places and events that are high-risk for you.  Avoid as many as possible and be creative in masking your non use in the event you must attend a drinking function.  For example, some people choose to have an empty beer can in their hand to keep from having to accept a drink.  Also, a glass of water will serve much the same purpose as the beer can.  Most people dont particularly care what a person is drinking as long as they have something in their hand.
  •         Identify emotions and feelings such as depression, anger, stress, boredom, loneliness, and euphoria that have been a factor in prior lapse or relapse.   Again, identify specific actions to take in the event these or similar emotions are encountered.  Look at activities with friends that include low risk stuff like movies, travel, exercise, reading or anything else that is appealing that will get your mind off the troublesome emotions.  Self management and avoidance are the keys to help manage negative emotions.
  •         Prioritize the aforementioned physical and emotional triggers to identify the highest risk factor to you and then work the highest priority first.  For example, if boredom is your highest priority than identify the specifics actions you will take to cope with that issue.  Continue down your list and develop alternative ways you can deal with each risk factor.  Experiment to see what works best for you.  Some will work better than others and some will not work at all.
  •         Program yourself to recognize that decisions always have consequences.  For example, the consequences related to resumption of drinking may result in health, family, social and legal problems as well as emotional problems (depression, grief, guilt and other psychological problems).  Once one begins to think along these lines they can be more objective and make better decisions.
  •         Be proactive in your recovery.  Remember it’s your life you are managing and it matters little what others think or do.  Most true friends will support your effort to remain abstinence.
  •         Obstacles and challenges are a part of recovery, don’t expect everything to be easy recognize each successful day is a victory and each successive day gets easier.  Make a firm commitment to sobriety and it will eventually become your standard.   Remember that millions of people have overcome alcohol and drug related problems and now live happy, productive and sober lives.