Definitions

12 Step Program

A set of guiding principles outlining a course of action from addiction to recovery, using a progression of twelve separate steps to help free the addict from the grip of drugs and alcohol.

Acceptance & Commitment Therapy

ACT is based on the idea that our suffering comes not from the experience of emotional pain, but from our attempted avoidance of that pain, which is only effective in the short-run and may cause greater problems in the long-run. The goal of this type of therapy is not to reduce symptoms but to learn how to accept and detach from them.

Cognitive Behavioral Therapy

CBT is a type of psychotherapy that helps you better understand your thoughts and feelings that can lead to problematic behavior. It is a way to recognize and challenge negative thinking, or certain situations and approaching it a new more effective way.

Dialectical Behavioral Therapy

DBT is a form of CBT focusing on psychosocial aspects, and relationships. It is support oriented in building on strengths and qualities to increase self-esteem. DBT helps to identify thoughts, beliefs, and assumptions that make life seem hard to deal with. Collaboration with the group or therapist involves constant attention to relationships between clients and staff. Individuals are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. Through these concepts it prepares the person to better deal with difficult situations.

Mindfulness

Is about changing our relationships to our thoughts, emotions, memories, allowing them to be as they are. It is paying attention in a particular way, on purpose in the present moment, non-judgmentally, bringing one’s complete attention to the present experience on a moment to moment basis. This is done through education, self-management (coping skills), social skills, and meaningful activity.

PAWS

Post Acute Withdrawl Syndrome is a set of symptoms that begin to set in immediately after an addict or alcoholic has detoxed from drugs or alcohol. Depending on the person and the severity and duration of their drug or alcohol use, PAWS symptoms may be light and short-lived in some cases, and debilitating and long-lasting in other cases.

Recovery

Things you are doing every day to stay clean/sober, involving a plan.

Relapse

Is not only using again, but is also returning to all behaviors and patterns that come with it, such a combination of feelings, thoughts, and ritualized behaviors that are subtly connected to your addiction. It also includes when a person stops participating in their own recovery plan such as not going to meetings, not reaching out for help, isolation, etc

Relapse Prevention

Developing a “plan” or strategies to stop the cycle of addictive behaviors. This involves education, increasing self-awareness, identifying triggers and high risk situations that may lead to relapse and developing a new way to deal with them. This can be done through 12-step programs, and varies therapy approaches to develop these life skills. Therapy programs include, Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Dialectical Behavioral Therapy (DBT), Mindfulness Behavioral Therapy, and individual therapy.

Causes and Warning Signs

Relapse is usually caused by a combination of factors. Some possible factors or triggers and warning signs to be aware of might be:

• negative emotional states (such as anger, sadness, trauma or stress)
• physical discomfort (such as withdrawal symptoms or physical pain)
• positive emotional states (wanting to feel even better)
• testing personal control (“I can have just one drink”)
• strong temptations or urges (cravings to use)
• conflict with others (such as an argument with a spouse or partner)
• social pressures to use (situations where it seems as though everyone else is drinking or using other drugs)
• good times with others (such as having fun with friends or family)
• Stopping medications on one’s own or against the advice of medical professionals
• Hanging around old drinking haunts and drug using friends – slippery places
• Isolating – not attending meetings – not using the telephone for support
• Keeping alcohol, drugs, and paraphernalia around the house for any reason
• Obsessive thinking about using drugs or drinking
• Failing to follow ones treatment plan – quitting therapy – skipping doctors appointments
• Feeling overconfident – that you no longer need support
• Relationship difficulties – ongoing serious conflicts – a spouse who still uses
• Setting unrealistic goals – perfectionism – being too hard on ourselves
• Changes in eating and sleeping patterns, personal hygiene, or energy levels
• Feeling overwhelmed – confused – useless – stressed out
• Constant boredom – irritability – lack of routine and structure in life
• Sudden changes in psychiatric symptoms
• Dwelling on resentments and past hurts – anger – unresolved conflicts
• Avoidance – refusing to deal with personal issues and other problems of daily living
• Engaging in obsessive behaviors – workaholism – gambling – sexual excess and acting out
• Major life changes – loss – grief – trauma – painful emotions – winning the lottery
• Ignoring relapse warning signs and triggers

Stages of Relapse

Emotional Relapse

In emotional relapse, you're not thinking about using. But your emotions and behaviors are setting you up for a possible relapse in the future.
The signs of emotional relapse are:
Anxiety, Intolerance, Anger, Defensiveness, Mood swings, Isolation, Not asking for help, Not going to meetings, Poor eating habits, Poor sleep habits
The signs of emotional relapse are also the symptoms of post-acute withdrawal (PAWS). Having an understanding of PAWS makes it easier to avoid relapse, because the early stage of relapse is easiest to pull back from. In the later stages the pull of relapse gets stronger and the sequence of events moves faster.
Techniques for dealing with emotional relapse
At this stage relapse prevention is means recognizing that you're in emotional relapse and changing your behavior. Recognize that you're isolating and remind yourself to ask for help. Recognize that you're anxious and practice relaxation techniques. Recognize that your sleep and eating habits are slipping and practice self-care. If you don't change your behavior at this stage and you live too long in the stage of emotional relapse you'll become exhausted, and when you're exhausted you will want to escape, which will move you into mental relapse.
Practice self-care. The most important thing you can do to prevent relapse at this stage is take better care of yourself. Think about why you use, for most it’s to escape, relax, or reward yourself. Therefore you relapse when you don't take care of yourself and create situations that are mentally and emotionally draining that make you want to escape. Like if you aren’t taking care of yourself and eat poorly or have poor sleep habits, you'll feel exhausted and want to escape. If you don't let go of your resentments and fears through some form of relaxation, they will build to the point where you'll feel uncomfortable in your own skin. If you don't ask for help, you'll feel isolated, and soon start thinking about using again. But if you practice self-care, you can avoid those feelings from growing and avoid relapse.

Mental Relapse

In mental relapse there's a war going on in your mind. Part of you wants to use, but part of you doesn't. In the early phase of mental relapse you're just idly thinking about using. But in the later phase you’re definitely thinking about using.
The signs of mental relapse are:
Thinking about people, places, and things you used with, Glamorizing your past use, Lying, Hanging out with old using friends’, Fantasizing about using, Thinking about relapsing, Planning your relapse around other people's schedules. It gets harder to make the right choices as the pull of addiction gets stronger.
Techniques for Dealing with Mental Urges:
When you think about using, the fantasy is that you'll be able to control your use this time. You'll just have one drink, one line, one bump. But continue with the thought. One drink usually leads to more drinks. You'll wake up the next day feeling disappointed in yourself. You may not be able to stop the next day, and you'll get caught in the same vicious cycle. When you complete the thought all the way through to its conclusion, using doesn't seem so appealing.
A common mental urge is that you can get away with using, because no one will know if you relapse. Your addiction will try to convince you that you don’t have a big problem, and that you're really doing your recovery to please other people, not because you need to. Follow that thought all the way through. Remind yourself of the negative consequences you've already suffered, and the potential consequences that can happen if you relapse again. If you could control your use, you would have done it by now.
Tell someone that you're having urges to use. Call a friend, a support, or someone in recovery. Share With them what you're going through. The concept of sharing allows us to talk about what you're thinking and feeling, which helps our urges begin to disappear. They don't seem quite as big and you don't feel as alone.
Distract yourself. When you think about using, do something to occupy yourself. Call a friend. Go to a meeting. Get up and go for a walk. If you just sit there with your urge and don't do anything, you're giving your mental relapse room to grow.
Wait for 30 minutes. Most urges usually last for less than 15 to 30 minutes. When you're in an urge, it feels like an eternity. But if you can keep yourself busy and do the things you're supposed to do, it will go away.
Do your recovery one day at a time. Don't think about whether you can stay abstinent forever. That's an overwhelming thought, almost setting you up for failure, even for people who've been in recovery for a long time.
One day at a time, means you should match your goals to your emotional strength. When you feel strong and you're motivated to not use, then tell yourself that you won't use for the next week or the next month. But when you're struggling and having lots of urges, and those times will happen often, tell yourself that you won’t use for today or for the next 30 minutes. Do your recovery in bite-sized chunks and don’t sabotage yourself by thinking too far ahead.

Physical Relapse

Once you start thinking about relapse, if you don't use some of the techniques you’ve learned, it doesn't take long to go from emotional or mental relapse to physical relapse. The next thing you know you’re driving to the liquor store or your dealers house.
It's hard to stop the process of relapse at that point. That's not where you should focus your efforts in recovery. That's achieving abstinence through brute force. But it is not recovery. If you recognize the early warning signs of relapse, and understand the symptoms of post-acute withdrawal, you'll be able to catch yourself before it's too late.

Stages of change

Precontemplation Stage

Not yet acknowledging that there is a problem behavior that needs to be changed.
These people are not thinking seriously about changing and are not interested in any kind of help. People in this stage tend to defend their current bad habit(s) and do not feel it is a problem. They may be defensive in the face of other people’s efforts to pressure them to quit.
Strategies:

• Even if you’re not convinced you need to change, keep track of your substance use. Write down when you use, what and how much you use, how you were feeling, where you were and who you were with. This will give you more information about the role of substance use in your life.
• Consider exploring your use to determine whether or not it is a problem; for example, take one of these short online questionnaires about your drinking or drug use.
• Consider making an appointment for an addiction assessment.
• Ask a friend or family member how he or she feels about your substance use.
• If any of these activities do raise some doubts in your mind, give yourself credit for seeing that your substance use may be a problem.

Contemplation Stage

Acknowledging that there is a problem, but not yet ready or sure of wanting to make a change.
These people are more aware of the personal consequences of their bad habit and they spend time thinking about their problem. Although they are able to consider the possibility of changing, they tend to be ambivalent about it
Strategies:

• Write down the pros and cons of changing your substance use.
• Ask yourself, “What do I need in order to be able to change?”
• Think about what’s most important to you (e.g., family, job, health). How does your substance use affect it?
• Don’t be discouraged if you’re not sure about making the change; many people feel the same way.

Preparation Stage

Getting ready to change.
These people have made a commitment to make a change. Their motivation for changing is reflected by statements such as: “I’ve got to do something about this — this is serious. Something has to change. What can I do?”
Strategies:

• Set a goal for change, such as a quit date or a target for cutting down on substance use.
• Learn about different addiction programs and services.
• Remind yourself of your reasons for making a change.
• Try not to expect big changes, and don’t minimize small changes.
• Get support from your friends and family.
• Think about your strengths and supports that will help you to change.
• Strategies in the action stage
• Seek support from others, such as family, friends and health professionals (e.g., your counselor or doctor).
• Attend an addiction treatment program and/or a self-help group.
• Avoid people, places and things that put you at risk of exceeding your substance use goals.
• Explore other treatment options, such as medication to reduce cravings, or residential treatment.

Action Stage

Changing behavior.
This is the stage where people believe they have the ability to change their behavior and are actively involved in taking steps to change their bad behavior by using a variety of different techniques.

Maintenance Stage

Maintaining the behavior change.
This involves being able to successfully avoid any temptations to return to the bad habit. The goal is to maintain the new changes. People in this stage tend to remind themselves of how much progress they have made.
Strategies:

• Be aware of urges and temptations to stray from your substance use goals.
• Continue to remind yourself of your reasons for making a change.
• Reward yourself for making the change. For example, do something “just for you” that you enjoy—perhaps a hobby or fun activity. However, don’t reward yourself with alcohol or another drug by having “just one.”
• Consider attending a relapse prevention group, aftercare program or self-help group.

Relapse

Returning to older behaviors and abandoning the new changes.
Strategies:

• Evaluate trigger for relapse
• Reassess motivation and barriers Plan stronger coping strategies

THE RELAPSE SYNDROME

When we attempt to stop an addictive behavior, we often try to just stop the behavior. Unfortunately, this does not usually work. Relapse generally follows a predictable and readily identifiable pattern. If you are able to identify this pattern for your own behavior, you will be better prepared to prevent relapse. This pattern usually takes the following steps:

Return of denial

Problem:
As the addict progresses in his program, he is likely to begin to feel that he has his problem under control. When asked how he is doing he is likely to say "fine, no problems" when, in fact, we all have problems that need to be dealt with regularly. This return of denial is often supported by those persons who strongly want you to be "cured".
Solution:

• Teach support people about recovery and relapse. Encourage them to probe you about problems.
• Write down your problems on a daily basis and share this list with someone.

Avoidance of defensive behavior

Problem:
As the addict begins to deny the potential for relapse, he drops his defensive behavior. He often will focus more energy on fixing others than on working on himself. He will begin placing himself in "at risk" situations and will stop doing his relapse prevention exercises.
Solution:

• Surround yourself with support people who will encourage you to continue working on your relapse prevention program.
• Maintain a "negative image" reminder of the price you paid for your addictive behavior.
• Develop and review a cost/benefit analysis of your coping behavior.

Crisis building

Problem:
As a result of avoiding defensive behavior, problems begin to pile up and it becomes more and more difficult to see options. The addict develops tunnel vision and loses the ability to perform constructive planning. Plans that were developed earlier often begin to fall apart.
Solution:

• Remind yourself to take one day at a time.
• Return to coping behavior.
• Accept your personal limits.
• Review the concepts of RET (RET states that it is your thoughts about an event and not the event that is "bad" or "good").

Immobilization

Problem:
When a crisis builds up, the addict becomes crushed and trapped by the problems. The addict becomes totally incapable of initiating action and is trapped by his own lies and problems. Often, the addict develops an unrealistic optimism wishing that things would "just go away". A sense that nothing can be solved may develop.
Solution:

• Use the Serenity Prayer.
• Use the support people that you have developed.
• Review the concept of lapse as opposed to relapse (accept the reality that you may make some small mistakes but this does not mean that you have failed).

Confusion and overreaction

Problem:
While the problems continue to grow and the addict feels stuck, he often becomes confused and angry. During this phase of the relapse syndrome, the addict may become irritable with those around him, develop a general sense of tension, and view others as out to get him.
Solution:

• Identify the source of the feelings.
• Accept responsibility for problems.
• Review RET concepts.
• Possible professional intervention.

Depression.

Problem:
As the anger begins to build, the addict begins to develop a sense of hopelessness and begins to turn the anger inward in the form of depression. Symptoms may include irregular eating habits, lack of desire to take action, irregular sleeping habits, loss of daily structure, and suicidal ideation.
Solution:

• Professional intervention.

Behavioral loss of control

Problem:
During this phase, the addict becomes unable to control or regulate personal behavior and a daily schedule. There is heavy denial and no full awareness of being out of control. Life becomes chaotic and many problems are created in all areas of life and recovery as indicated by irregular support meeting attendance, open rejection of help, and feelings of powerlessness and helplessness.
Solution:

• Professional intervention.

Recognition of loss of control

Problem:
The addict's denial breaks and suddenly he recognizes how severe the problems are and panics. As a result of this panic, the addict may begin self-pity, return to deviant fantasies, consciously lie, and lose self-confidence.
Solution:

• Professional intervention.
• Return to self-help programs (ie. SLAA, AA, etc.).

Option reduction

Problem:
During this phase the addict feels trapped by the pain and inability to manage life. Only three options seem possible--insanity, suicide, or relapse. The addict believes that nobody can help. Common symptoms include: unreasonable resentment, discontinuance of all treatment, and overwhelming loneliness, frustration, anger, and tension.
Solution:

• Forced treatment.
• Revocation.

Acute relapse episode

Problem:
Return to the abusive behavior.

Tools for avoiding relapse

• Staying away from the first “drink”
  -“if you don’t take the first drink, you can’t get drunk”
  -“One drink is too many, and 20 is not enough”
  -Avoid thinking “just one more time… one more hit… one more drink.. will be ok”
  -Instead of planning to “never” use again or trying to limit yourself to just “one” try thinking in short term goals…. “I’m not going to use today, or this week”
• Using the 24-hour plan
  -Staying clean and sober just for today
  -Take it one day at a time, one hour at a time, or one minute at a time
• Remembering drug addiction is an incurable, progressive, and fatal disease
  -Just like with any illness or disease you must make life changes to survive, along with new way of thinking and dealing with stressors.
  -Can be done through education, therapy, and having a plan
• Live & Let Live
  -Accept the realization that there are people in all areas of life who sometimes say or do things we disagree with, and we must learn to live with these differences.
• Getting Active
  -Good form of distraction
  -Service work within 12-step program, go for a walk, exercise, reading, going out to library, museum, to a movie, etc.
• Serenity Prayer
  -God grant me the serenity to accept the things I cannot change, the Courage to change the things I can, and the Wisdom to know the difference
  -You don’t have to 12-step or believe in God
• Changing old routines
  -Our old routines can be triggers
  -Changing routines from your what you do when you get up, during the day, to the route you take to a familiar place
• Eating or drinking something (usually sweet)
  -This can help with cravings (especially chocolate)
• Reach out
  -Get numbers at meetings, call a friend or family member, or even a hotline, talking about it can help, especially to someone who understands
• Get a sponsor
  -This helps when working a 12-step program, a friendly guide and someone to call when you need help
• Getting plenty of rest
  -This helps your body restore itself, don’t forget to give yourself some TLC
• Be conscious of anger & resentment
  -A very common thing that leads to using
  -Anger management classes
• Looking out for triggers
  -Identify your triggers, be aware of them, and develop a plan for a different way to deal with them
• Gratitude
  -Having an Attitude of Gratitude
  -Be aware what you are grateful for!
• Keeping “fresh” in your mind the last time you used
• Avoiding certain prescription and over-the-counter medications
  -Easy to “switch” addictions, also some drugs may be a trigger
• Eliminate self-pity
• Avoid emotional entanglements
• Avoid “what if” type of thinking
• Letting go of old ideas, habits, places, & people
  -This isn’t an easy task, it takes work including making life changes, but will help change your attitude towards using

Myths

Myths and untrue statements concerning relapse and recovery

• Not working your program causes relapse
• A person who relapses is not willing to stop
• A person knows they are relapsing
• Not using means you’re in recovery

 

References

1. Alcoholics Anonymous World Services, Inc. (1975) Living Sober. New York, New York: A.A. World Services Inc.
2. Gorski, T.T., & Miller, M. (1986). Staying Sober, A Guide For Relapse Prevention. Independence, Missouri: Herald House.
3. Gross, S. J.(2013) Growing Ourselves Up: A Guide to Recovery and Self-Esteem.
   
4. Hedges, B. A. (1999) Relapse Prevention Workbook. Ohio: Mid-Ohio Psychological Services, Inc.
5. Melemis, S.M. (2010). I Want to Change My Life: How to Overcome Anxiety, Depression and Addiction. Modern Therapies.
6. The Stages of Change. (n.d.). Retrieved February 23, 2013 from http://www.cpe.vt.edu/gttc/presentat...esofChange.pdf

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