How to develop a Relapse Prevention plan
People 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.
There are nine steps in
learning to recognize and stop the early warning signs of
relapse.
Step
1: Stabilization:
Relapse 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 today?"
Step
2: Assessment:
The 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.
By 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.
The 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 these memories.
Once 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?
Finally, 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
abstinence.
Comprehensive 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!"
A 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.
That 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.
Every 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 pressures.
By 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.
It 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.
Step 3: Relapse Education:
Relapsers 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 becomes
unnecessary.
When 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 sober.
Step
4: Warning Sign Identification:
Relapsers 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.
There 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."
Jake, 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.
Most 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.
After 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 story.
Jake, 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."
The 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.
Jake 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.
I 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 wrote:
(1) 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 anyone.
(2) 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 rest.
(3) 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.
With 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.
Understanding 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 drug use.
This 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 stress.
Warning Sign:
I know I am in trouble with my recovery when I feel unable to
cope with high levels of job-related stress.
General Coping Strategy:
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 unwind.
The 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:
Irrational Thought:
I need to try harder in order to get things under control or
else I will be a failure.
Rational Thought:
I am burned out because I am trying to hard. I need to time to
rest or I will start making more mistakes.
Unmanageable Feelings:
Humiliation and embarrassment.
Feeling Management Strategy:
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.
Self-defeating Behavior:
Driving myself to keep working even thought I know I need to
rest.
Constructive Behavior:
Take a break and relax. Ask someone to review the project and
see if they can help me to solve the problem.
Now 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 recovery.
Jake 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 became overwhelming.
The 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.
The 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.
If 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.
The 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.
If you or a loved one need help immediately, please do call us as soon as possible. We are always on call and willing to help if given the opportunity. Please call The Awakening at 1-877-888-9858 .
