who relapse aren't suddenly taken drunk. Most
experience progressive warning signs that reactivate denial and cause so much
pain that self-medication with alcohol or drugs seems like a good idea.
This is not a conscious process. These
warning signs develop automatically and unconsciously.
Since most recovering people have never been taught how to identify and
manage relapse warning signs, they don't notice them until the pain becomes too
severe to ignore.
are nine steps in learning to recognize and stop the early warning signs of
prevention planning probably won't work unless the relapser is sober and in
control of themselves. Detoxification
and a few good days of sobriety are needed in order to make relapse prevention
planning work. Remember that many
patients who relapse are toxic. Even
though sober they have difficulty thinking clearly, remembering things and
managing their feelings and emotions. These
symptoms get worse when the person is under high stress or is isolated from
people to talk to about the problems of staying sober.
To surface intense therapy issues with someone who has a toxic brain can
increase rather than decrease the risk of relapse.
In early abstinence go slow and focus on basics.
The key question is "What do you need to do to not drink
assessment process is designed to identify the recurrent pattern of problems
that caused past relapses and resolve the pain associated with those problems.
This is accomplished by reconstructing the presenting problems, the life
history, the alcohol and drug use history and the recovery relapse history.
reconstructing the presenting problems the here and now issues that pose an
immediate threat to sobriety can be identified and crisis plans developed to
resolve those issues.
life history explores each
developmental life period including childhood, grammar school, high school,
college, military, adult work history, adult friendship history, and adult
intimate relationship history. Reviewing
the life history can surface painful unresolved memories.
It's important to go slow and talk about the feelings that accompany
the life history is reviewed, a detailed alcohol
and drug use history is reconstructed.
This is be done by reviewing each life period and asking four questions:
(1) How much alcohol or drugs did you use?
(2) How often did you use it? (3)
What did you want alcohol and drug use to accomplish? and
(4) What were the real consequences, positive and negative, of your use?
In other words, did the booze and drugs do for you what you wanted it to do
during each period of your life?
the recovery and relapse history is reconstructed. Starting with the
first serious attempt at sobriety each period of abstinence and chemical use is
carefully explored. The major goal
is to find out what happened during each period of abstinence that set the stage
for relapse. This is often
difficult because most relapsers are preoccupied with their drinking and
drugging and resist thinking or talking about what happened during periods of
assessments have shown that most relapsers get sober, encounter the same
recurring pattern of problems, and use those problems to justify the next
relapse. As one person put it "It is not one thing after the
other, it is the same thing over and over again!"
23 year old relapser named Jake reported drinking about a six pack of beer every
Friday and Saturday night during high school.
He did it in order to feel like he was part of the group, relax and have
fun. at that stage in his addiction
the beer did exactly what he wanted it to do.
all changed when Jake left school and went to work as a salesman.
He had to perform in a high pressure environment and felt stressed.
The other salesmen were competitive and no matter what he did they
wouldn't let him belong. He began drinking bourbon every night to deal with the
stress. He wanted to feel relaxed
so he could cope better at work. He
consistently drank too much and woke up with terrible hangovers that caused new
problems with his job.
time Jake would attempt to stop drinking he would feel isolated and alone and
become overwhelmed by the stress of his job.
Even when with others at Twelve Step Meetings he felt like he didn't
belong and couldn't fit in. As the
stress grew he began to think "If this is sobriety who needs it?"
Each relapse was related with his inability to deal with job related
comparing the life history, the alcohol and drug use history, and the recovery
relapse history Jake could see in a dramatic way the recurrent problems that
caused him to relapse. The two major issues were (1) the need to drink in order
to feel like he belonged and (2) the need to drink in order to cope with stress.
wasn't surprising that Jake discovered that during every past period of
abstinence he became isolated, lonely and depressed.
The longer he stayed sober the worse it got.
The stress built up until he felt that if he didn't take a drink to relax
he would go crazy or collapse.
need to learn about the relapse process and how to manage it.
It's not a bad idea to get their family and Twelve Step Sponsors
involved. The education needs to
reinforce four major messages: First,
relapse is a normal and natural part of recovery from chemical dependence.
There is nothing to be ashamed or embarrassed about.
Second, people are not suddenly taken drunk.
There a progressive patterns of warning signs that set them up to use
again. These warning signs can be
identified and recognized while sober. Third,
once identified recovering people can learn to manage the relapse warning signs
while sober. And Fourth, there is hope. A
new counseling procedure called relapse prevention therapy can teach recovering
people how to recognize and manage warning signs so a return to chemical use
Jake entered relapse prevention therapy he felt demoralized and hopeless.
That began to change when he heard his first lecture that described the
typical warning signs that precede relapse to chemical use. He felt like someone had read his mail. "Since someone understand what causes me to get
drunk," he thought, "perhaps they know what to do in order to stay
need to identify the problems that caused relapse. The goal is to write a list of personal warning signs
that lead them from stable recovery back to chemical use.
is seldom just one warning sign. Usually
a series of warning signs build one on the other to create relapse.
It's the cumulative affect that wears them down. The final warning sign
is simply the straw that breaks the camel's back.
Unfortunately many of relapsers think it's the last warning sign that did
it. As a result they don't look for the earlier and more subtle warning signs
that set the stage for the final disaster.
When Jake first came into relapse prevention therapy he thought that he
was crazy. "I can't understand
it," he told his counselor, "Everything was going fine and suddenly,
for no reason at all I started to overreact to things.
I'd get confused, make stupid mistakes and then not know what to do to
fix it. I got so stressed out that
I got drunk over it."
like most relapsers, didn't know what his early relapse warning signs were and
as a result didn't recognize the problems until it was too late.
A number of procedures are used to help recovering people identify the
early warning signs relapse.
people start by reviewing and discussing The Phases And Warning Signs Of
Relapse (available from Independence Press, PO Box HE, Independence MO
64055, 1-800-767-8181). This
warning sign list describes the typical sequence of problems that lead from
stable recovery to alcohol and drug use. By
reading and discussing these warning signs relapsers develop a new way of
thinking about the things that happened during past periods of abstinence that
set them up to use. They learn new
words with which to describe their past experiences.
reading the warning signs they develop an initial warning sign list by selecting
five of the warning signs that they can identify with.
These warning signs become a starting point for warning sign analysis. Since most relapsers don't know what their warning signs are
they need to be guided through a process that will uncover them.
The relapser is asked to take each of the five warning signs and tell a
story about a time when they experienced that warning sign in the past while
sober. They tell these stories both
to their therapist and to their therapy group.
The goal is to look for hidden warning signs that are reflected in the
for example, identified with the warning sign "Tendency toward
loneliness." He told a story about a time when he was sober and all alone
in the house because his wife had left with the children.
"I felt so lonely and abandoned, he said. I
couldn't understand why she would walk out just because we had a fight.
She should be able to handle it better than she does."
group began asking questions and it turned out that Jake had frequent arguments
with his wife that were caused by his grouchiness because of problems on the
job. It turned out that these family arguments were a critical
warning sign that occurred before most relapses.
Jake had never considered his marriage to be a problem, and as a result
never thought of getting marriage counseling.
had now identified three warning signs: (1)
the need to drink in order to feel like he belonged, (2) the need to drink in
order to cope with stress, and (3) the need to drink in order to cope with
marital problems. In order to be
effectively managed each of these warning would need to be further clarified.
then had Jake to write these three warning signs using a standard format and
identify the irrational thoughts, unmanageable feelings and self defeating
behavior that accompanied each. He
I know I am in trouble with my recovery when I feeling lonely and unable to fit
in with other people; When
this happens I tend to think that I am no good and nobody could ever care about
me. When this happens I tend to feel lonely, angry and afraid. When
this happens I have an urge to hide myself away so I don't have to talk with
I know I am in trouble with my recovery when I feel unable to cope with high
levels of job-related stress; When this happens I tend to think that I
need to try harder in order to get things under control or else I will be a
failure. When this happens I tend to feel humiliated and embarrassed.
When this happens I drive myself to keep working even thought I know I need to
I know I am in trouble with my recovery when I irrationally angry at my wife.
When this happens I tend to think that I'm a terrible person for treating her
that way, but a part of me believes she deserves it. When this I happens I
tend to feel angry and ashamed. When this happens forget that the incident
ever happened, put it behind us and get on with our marriage.
this detailed description of the relapse warning signs Jake was ready to move on
to the fifth step of relapse prevention planning,
warning sign management.
the warning signs is not enough. We
need to learn how to manage them without resorting to alcohol or drug use.
This means learning nonchemical problem solving strategies that help us
to identify high risk situations and develop coping strategies.
In this way relapsers can diffuse irrational thinking, manage painful
feelings, and stop the self-defeating behaviors before they lead to alcohol or
is done by taking each relapse warning sign and developing a general coping
strategy. Jake, for example
developed the following management strategy for dealing with his job related
Sign: I know I am in trouble with my
recovery when I feel unable to cope with high levels of job-related stress.
I will learn how to say no to taking on extra projects, limit my work to
45 hours per week, and learn how to use relaxation exercises and meditation to
next step is to identify ways to cope with the irrational thoughts, unmanageable
feelings, and self-defeating behaviors that accompany each warning sign.
Jake developed the following coping strategies:
Thought: I need to try harder in order to get things under control or
else I will be a failure.
Thought: I am burned out because I am trying to hard.
I need to time to rest or I will start making more mistakes.
Feelings: Humiliation and embarrassment.
Talk about my feelings with others.
Remind myself that there is no reason to embarrassed.
I am a fallible human being and all people get tired.
Behavior: Driving myself to keep
working even thought I know I need to rest.
Behavior: Take a break and relax.
Ask someone to review the project and see if they can help me to solve
Jake is ready to move unto the sixth step of
recovery planning. A recovery
plan is a schedule of activities that puts relapsers into regular contact with
people who will help them to avoid alcohol and drug use.
They must stay sober by working the twelve step program and attending
relapse prevention support groups that teach them to recognize and manage
relapse warning signs. This is why
I call relapse prevention planning a "Twelve Step Plus" approach to
needed to build something into his recovery program to help him deal with job
related stress. He decided to enter
into counseling with a counselor who specialized in stress management,
understood chemical dependency and had a background as an employee assistance
counselor. By doing this Jake was
forced to regular discuss his problems at work and review how he was coping with
them. By identifying job related
problems early, he could prevent getting overwhelmed by small problems that
seventh step is inventory training. Most
relapsers find it helpful to get in the habit of doing a morning and evening
inventory. The goal of the morning
inventory is to prepare to recognize and manage warning signs.
The goal of the evening inventory is to review progress and problems.
This allows relapsers to stay anticipate high risk situations and monitor
for relapse warning signs. Relapsers
need to take inventory work seriously because most warning signs are deeply
entrenched habits that are hard to change and tend to automatically come back
whenever certain problems or stresses occur.
If we aren't alert we may not notice them until it's too late.
eighth step is family involvement. A
supportive family can make the difference between recovery and relapse.
We need to encourage our family members to get involved in Alanon so they
can recover from codependency. With
this foundation of shared recovery we can beginning talking with our families
about past relapses, the warning signs that led up to them, and how the relapse
hurt the family. Most importantly
we can work together to avoid future relapse.
we had heart disease we would want our family to be prepared for an emergency.
Chemical dependency is a disease just like heart disease.
Our families' needs to know about the early warning signs that lead to
relapse. They must be prepared to
take fast and decisive action if we return to chemical use.
We can work out in advance, when we are in a sober state of mind, the
steps they should take if we return to chemical use.
Our very life could depend upon it.
final step is follow-up. Our warning
signs will change as we progress in recovery.
Each stage of recovery has unique warning signs.
Our ability to deal with the warning signs of one stage of recovery
doesn't guarantee that we will recognize or know how to manage the warning signs
of the next stage. Our relapse
prevention plan needs to be updated regularly; monthly for the first three
months, quarterly for the first two years, and annually thereafter.
Published In: Alcoholism &
Addiction Magazine: Relapse - Issues and Answers: Column 3:
How To Develop A Relapse Prevention Plan: By Terence T. Gorski, September
25, 1989; 708-799-5000, www.cenaps.com.