The Phases and Warning Signs of Relapse

RETURN OF DENIAL: During this phase the dependent person becomes unable to recognize and honestly tell others what he or she is thinking or feeling. The most common symptoms are:
1. Concern about well being.
2. Denial of the concern.

AVOIDANCE AND DEFENSIVE BEHAVIOR: During this phase the dependent person doesn't want to think about anything that will cause painful and uncomfortable feelings to come back. As a result, he or she begins to avoid anything or anybody that will force an honest look at self. When asked direct questions about well-being, he or she begins to become defensive. The most common symptoms are:

1. Believing "I'll never drink again."
2. Worrying about others instead of self.
3. Defensiveness.
4. Compulsive behavior.
5. Impulsive behavior.
6. Tendencies toward loneliness.

CRISIS BUILDING: During this phase the dependent person begins experiencing a sequence of life problems that are caused by denying personal feelings, isolating self, and neglecting the recovery program. Even though he or she wants to solve these problems and work hard at it, two new problems pop up to replace every problem that is solved. The most common symptoms are:
1. Tunnel vision.
2. Minor depression.
3. Loss of constructive planning.
4. Plans begin to fail.

IMMOBILIZATION: During this phase the dependent person is totally unable to initiate action. He or she goes through the motions of living, but is controlled by life rather than controlling life. The most common symptoms are:
1. Daydreaming and wishful thinking.
3. Feeling that nothing can be solved.
3. Immature wish to be happy.

CONFUSION AND OVERREACTION: During this phase the dependent person can't think clearly. He or she becomes upset with self and those around her or him and is irritable and overreacts to small things.
1. Periods of confusion.
2. Irritation with friends.
3. Easily angered.

DEPRESSION: during this phase the dependent person becomes so depressed that he or she has difficulty keeping to normal routines. At times there may be thoughts of suicide, drinking, or drug use as a way to end the depression. The depression is severe and persistent and cannot be easily ignored or hidden from others. The most common symptoms are:

1. Irregular eating habits.
2. Lack of desire to take action.
3. Irregular sleeping habits.
4. Loss of daily structure.
5. Periods of deep depression.

BEHAVIORAL LOSS OF CONTROL: During this phase the dependent person becomes unable to control or regulate personal behavior and daily schedule. There is still heavy denial and no full awareness of being out of control. His or her life becomes chaotic and many problems are created in all areas of life and recovery. The most common symptoms are:
1. Irregular attendance at AA and treatment meetings.
2. Development of an "I don't care attitude."
3. Open rejection of help.
4. Dissatisfaction with life.
5. Feeling of powerlessness and helplessness.

RECOGNITION OF LOSS CONTROL: The dependent person's denial breaks and suddenly he or she recognizes how severe the problems are, how unmanageable life has become, and how little power and control he or she has to solve any of the problems. This awareness is extremely painful and frightening. By this time he or she has become so isolated that it seems that there is no one to turn to for help. The most common symptoms are:
1. Self-pity.
2. Thoughts of social drinking.
3. Conscious lying.
4. Complete loss of self-confidence.

OPTION REDUCTION: During this phase the dependent person feels trapped by the pain and inability to manage his or her life. There seem to be only three ways out--insanity, suicide, or drug use. This person no longer believes that anyone or anything can help him. The most common symptoms are:

1. Unreasonable resentment.
2. Discontinues all treatment and AA.
3. Overwhelming loneliness, frustration, anger and tension.
4. Loss of behavioral control.

THE RELAPSE EPISODE: During this phase the dependent person begins to use alcohol or drugs again, typically struggling to control or regain abstinence. This struggle leads to shame and guilt when the attempt ultimately fails. Eventually all control is gone and serious bio-psycho-social problems develop and continue to progress. The most common symptoms are:
1. Initial use (the lapse).
2. Shame and guilt.
3. Helplessness and hopelessness.
4. Complete loss of control.
5. Bio-psycho-social damage.

Source: http://nmbon.sks.com/uploads/FileLinks/d2be4887fe8948e7b95df0793ca4378a/DP_phases_and_warning_signs_of_relapse.pdf

Why Alcoholics Stay Addicted

Biological Factors

• Biological vulnerability and genetic predisposition in interaction with certain facilitating environments create problems and eventually disease.
• Pharmacological impact of excessive use of alcohol and other drugs on body chemistry, physiology , and the organ systems of the body.
• Tolerance – Increased frequency of use and higher doses over time.
• Withdrawal – Negative effects of cessation of addictive behaviors.
• Higher risk of developing specific physical disorders (diseases) associated with the chronic and excessive use of particular substances.

Psychological Factors

• Motivation – Stages of habit initiation and stages of habit change.
• Expectancies – Positive outcomes of drug use and self-efficacy.
• Attributions – Effects of substance use and reasons for relapse.
• Sensation-Seeking – Excessive need for stimulation
• Impulsivity – Inability to effectively control or restrain behavior.
• Negative Affect – Dysphoric moods such as anxiety & depression.
• Poor Coping – Deficits in cognitive and behavioral skills or inhibitions in the ability to perform behaviors due to the effects of anxiety.

Sociocultural Factors

• Family History – Dysfunctional family settings especially parental alcohol and drug problems and parental abuse or neglect of children.
• Peer Influences – Social pressure to engage in risk-taking behaviors including substance use especially when related to gang membership.
• Culture and Ethnic Background – Norms and religious beliefs that govern the use of alcohol and drugs and ethnic variations the body’s rate and efficiency of metabolizing drugs and alcohol.
• Media/Advertising – Societal emphasis on immediate gratification and glorification of the effects of alcohol and drug use.

Source: http://depts.washington.edu/abrc/RP_new.ppt

Abstinence vs. Controlled Drinking

There are two opposing ideas regarding whether abstinence or controlled drinking should be the goal of recovery. Controlled drinking means that alcoholics are given separate forms of therapeutic treatments to eventually begin drinking in moderation as long as their intake does not result in signs of dependence, intoxication, legal, or health problems (Luty, 2006). This completely goes against the philosophy of Alcoholics Anonymous, who maintain that abstinence is the only way for alcoholics to recover, and if they are able to eventually drink in moderation then they were only alcohol abusers, not alcoholics. According to Luty (2006), research suggests that:

 "controlled drinking may be an option for young, socially stable drinkers with short, less severe drinking histories (e.g. alcohol consumption of less than 4 units per day with normal liver function tests). An individual’s belief that controlled drinking is an achievable goal is also a good prognostic factor. Most authors agree that controlled drinking should not be recommended for people with heavy dependence or those with protracted alcohol problems."

Luty (2006) mentions one study 70 individuals were divided into two groups, one with the goal of abstinence and the other with a goal of controlled drinking. Apparently there were very little differences in the success rates of either group; consumption was reduced to 51 to 13 drinks per week and 40–50% of participants had relapsed at 6 months, and at 2 years both groups had not shown a significant difference in rates of drinking and relapse.

According to Luty (2006), it appears that regardless of the counselor's recommended goal (abstinence or controlled drinking), the client decides for themselves which path they will follow. Since different techniques are used to treat clients with each of these goals, and the initial focus of this blog will be on abstinence as the desired outcome.

Luty, J. 2006. What works in alcohol use disorders? Retrieved from: http://apt.rcpsych.org/content/12/1/13.full.pdf.

Relapse Prevention Therapies

There are several therapies used in the treatment of alcohol addiction and relapse prevention. The list below offers a brief summary of some of the most recommended methods, and further information on many of them is available in some of the other posts and slides posted on the blog. Keep in mind that the client's age, gender, ethnicity, religious background, and other characteristics will impact the treatment that is used. Resources for some of these particular populations are linked in the Additional Resources section.

Relapse Prevention Therapy (RPT)

RPT is a cognitive-behavioral approach to treating addiction and specifically relapse. RPT intervention strategies include coping skills training, thought management, and lifestyle modification. Much of the information presented on this blog incorporates RPT and cognitive-behavioral methods of treating alcohol addiction. For a thorough guideline on incorporating RPT please see this resource: http://www.bhrm.org/guidelines/RPT%20guideline.pdf

Motivational Interviewing

The clients themselves give reasons why they should be abstinent and draw up a list of problems caused by their alcoholism. See the blog post below for more information on this form of therapy.

Twelve-Step Facilitation

Programs where clients either individually (such as in project MATCH) or in a group setting (like Alcoholics Anonymous) progress through a series of steps involving self-discovery, healing/coping skills, and support mechanisms in order to complete their recovery. This form of treatment is often used as a primary or supplementary form of therapy.

Community reinforcement approach

A friend or family member participates in the recovery of the addict by providing positive reinforcers to reward abstinence and negative reinforcers to punish drinking. Radio, television, newspapers, telephone or driving licence are examples of reinforcers. The spouse or friend may also help reinforce other aspects of treatment such as relapse prevention group attendance, counseling sessions, and the addict's use of disulfiram prescription. You can find more information here: http://pubs.niaaa.nih.gov/publications/arh23-2/116-121.pdf

Social behavior and network therapy

Alcoholics build support networks using cognitive-behavioral and community reinforcement approach principles. 

Contingency management

"Contingency management is designed to reinforce small steps, especially at the beginning, like celebrating each attendance at a group meeting or each drug-free test result. Later, patients can move on to larger achievements like stable housing. Easy-to-earn material goods, such as movie passes and food vouchers, help to both initiate and maintain positive changes." (Rockefeller University, 2005). According to Luty (2006), contingency management (or planning) is generally considered an addition to therapy rather than a substitute, and the fact that some reinforcements may 'pay' alcoholics not to drink makes this form of treatment controversial. "Furthermore, there is a tendency to relapse when the reinforcing regime is ended. This may explain the reluctance of many services to introduce contingency managemen"t (Luty, 2006). Further information can be found here: http://pubs.niaaa.nih.gov/publications/arh23-2/122-127.pdf

Cue exposure
Cue exposure involves repeated exposure to triggers in an attempt to extinguish cravings and other undesirable responses.

Therapeutic Communities and Rehabilitation Centers

Therapeutic communities usually require several months to years of residence with extensive participation by the clients. Costs for these programs tend to be high and many are criticized as employing outdated treatment methods, but research has found that "low-cost, publicly funded clinics have better-qualified therapists and better outcomes than the high-end residential centers typically used by celebrities like Britney Spears and Lindsay Lohan" (Brody, 2013).  Given the relapse rates of addicts who attend "rehab" facilities, some encourage "that most people recover (1) completely on their own, (2) by attending self-help groups, and/or (3) by seeing a counselor or therapist individually" (Brody, 2013).


Relapse Prevention Plans

The development of a relapse prevention plan is often an intended outcome or useful by-product of many of these therapies. More information on building these plans can be found in the top right section of the blog titled: "9 Steps to Building a Relapse Prevention Plan."

References

Brody, J.E. 2013. Effective addiction treatment. Retrieved from http://well.blogs.nytimes.com/2013/02/04/effective-addiction-treatment/. 

Luty, J. 2006. What works in alcohol use disorders? Retrieved from: http://apt.rcpsych.org/content/12/1/13.full.pdf.

Rockefeller University. 2005. 'Contingency Management' Improves Addiction Recovery: Program Reinforces Each Small Step Toward Success. Retreived from: http://alcoholism.about.com/od/relapse/a/blru050402.htm

Motivational Interviewing

Client (lack of) motivation, and resistance may very well be one of the most frustrating aspects of working as a counselor. Since trying to inform alcoholics on the consequences of drinking and benefits of abstinence often provokes the client to offer opposing arguments and resistance, it may be useful to put the job of reasoning the pitfalls of drinking into the client's lap. This is where motivational enhancement therapy (also called motivational interviewing) has gained traction and use in treating clients with addiction.

One helpful acronym when implementing motivational interviewing is:

F      Provide Feedback on behaviour
R      Reinforce the patient’s Responsibility for changing behaviour
A     State your Advice about changing behaviour
M    Discuss a Menu of options to change behaviour
E     Express Empathy for the patient
S     Support the patient’s Self-efficacy

Motivational interviewing is a confrontational form of therapy, yet unique in that the conflict intended to give rise to change does not occur between the therapist and the client; it should arise within the client as they work through brainstorming sessions where they discuss topics that normally the counselor might ask questions to educate and bring the client towards desired changes in thoughts and behavior.

"A guideline suggested by practitioners is that one should aim to increase the proportion and accuracy of reflective listening statements and decrease the proportion of questions. The more thoughtful and understanding is the practitioner, the more likely the patient is to become contemplative and, in doing so, to make new connections... In the example below, a client is engaged in talking about ambivalence. The counsellor’s task is not to jump ahead to any other topic but merely to allow the client to explore this conflict. Simple reflective listening statements are used to do this.

Counsellor: So what have you noticed about the effect of alcohol on your mood?

Client: It’s like my saviour, because you see it is sometimes the only time I really feel at peace with myself, like really relaxed.

Counsellor: It comes over you and you feel so different.

Client: Yes, and this goes on for a long time. There can be all hell breaking loose around me and I won’t let it touch me.

Counsellor: It protects you from all sorts of troubles.

Client: For a while and then it’s like my punishment is not far away, like the time will come when I feel upset, little things, and I get upset and even angry.

Counsellor: You get this lovely lift and you also get these darker moments.

Client: Exactly, but they don’t just last for a moment. You should see what I am like the next day, I feel really down, like my life is a roller coaster of highs and lows, and the drink is my master. I don’t like that."

Having learned the downside of relying on questions as a counselor, motivational interviewing seems like a valuable resource for getting clients to discover the discrepancies in their personal goals and the destruction alcohol is wreaking on those goals.  

For more information and examples see: The Essential Handbook of Treatment and Prevention of Alcohol Problems: Ch. 7 Motivational Interviewing

Self-Talk

One of the tools that may help alcoholics cope with cravings is something called Self-Talk. Some automatic thoughts clients have only lead them down a slippery slope of giving up:

"Ugh I want a drink. I won't be able to stand this. The urge is going to keep getting stronger and stronger until I blow up or drink."

Other types of self-statements can make the urge easier to handle:

"Even though my mind is made up to stay sober, my body will take a while to learn this too. This urge is uncomfortable, but in 15 minutes or so, I'll be feeling like myself again."

There are two basic steps in using self-talk constructively:

1. Have the client pinpoint what they tell him- or herself about a craving that makes it harder to cope with the urge. One way to tell if the client is on the right track is when he or she hits upon a self-statement that increases their discomfort. That discomfort-raising self-statement is a leading suspect for challenge, since it pushes their buttons.

2.    Use self-talk constructively to challenge that statement. An effective challenge will make the client feel better (less tense, anxious, panicky) even though it may not make the feelings disappear entirely. The most effective challenges are ones that are tailored to the client's specific upsetting self-statements.

Examples of challenges the client can pose to themselves:

What is the evidence? What is the evidence that if you don't have a drink in the next 10 minutes, you will die? Has anyone (who has been detoxed) ever died from not drinking? What's the evidence that people who are recovering from an alcohol problem don't experience the feelings that you have? What is the evidence that there is something the matter with you, that you will never improve? Of course you can survive it. Who said that sobriety would be easy? What's so terrible about experiencing an urge? If you hang in there, you will feel fine. These urges are not like being hungry or thirsty - they are more like a craving for food or an urge to talk to a particular person- they pass, in time.

Some of the substitute thoughts or self-statements will only be necessary or helpful initially, as ways of distracting the client from persistent urges; the client will have an easier time if they replace the uncomfortable thoughts with other activities. After a while, sobriety will feel less unnatural; many of the urges will diminish and drop out, and the client won't need constant replacements. 

Adapted from: http://pubs.niaaa.nih.gov/publications/matchseries3/project%20match%20vol_3.pdf

Urge Surfing

Many people try to cope with their urges by gritting their teeth and toughing it out. Some urges, especially when the client first returns to their old drinking environment, are just too strong to ignore. When this happens, it can be useful for the client to stay with their urge to drink until it passes. This technique is called urge surfing. Urges are a lot like ocean waves. They are small when they start, grow in size, and then break up and dissipate. The client can imagine him- or herself as a surfer who will ride the wave, staying on top of it until it crests, breaks, and turns into less powerful, foamy surf.

There are three basic steps in urge surfing that you can encourage the client to participate in:

1. Take an inventory of how you experience the craving. Do this by sitting in a comfortable chair with your feet flat on the floor and your hands in a comfortable position. Take a few deep breaths and focus your attention inward. Allow your attention to wander through your body. Notice where in your body you experience the craving and what the sensations are like. Notice each area where you experience the urge, and tell yourself what you are experiencing. For example, "Let me see... My craving is in my mouth and nose and in my stomach."

2.   Focus on one area where you are experiencing the urge. Notice the exact sensations in that area. For example, do you feel hot, cold, tingly, or numb? Are your muscles tense or relaxed? How large an area is involved? Notice the sensations and describe them to yourself. Notice the changes that occur in the sensation. "Well, my mouth feels dry and parched. There is tension in my lips and tongue. I keep swallowing. As I exhale, I can imagine the smell and tingle of booze."

3. Repeat the focusing with each part of your body that experiences the craving. Pay attention to and describe to yourself the changes that occur in the sensations. Notice how the urge comes and goes. Many people, when they urge surf, notice that after a few minutes the craving has vanished. The purpose of this exercise, however, is not to make the craving go away but to experience the craving in a new way. If you practice urge surfing, you will become familiar with your cravings and learn how to ride them out until they go away naturally. 

Adapted from: http://pubs.niaaa.nih.gov/publications/matchseries3/project%20match%20vol_3.pdf

12 Step Programs

12 Step programs like Alcoholics Anonymous (AA) have proven effective in helping many remain sober for years, but they are not for everyone. When considering such programs you may wish to discuss the following with your client: 

Pros

• Free and unlimited
• No wait time
• Everyone is accepted
• The other group participants understand the problem through personal experience
• Structure to the "recovery" process (12 steps) you can do without a counselor

Cons

• May cause more difficulties for people with problems such as depression and social anxiety
• Other people's stories can be a trigger to relapse
• Unregulated participants' advice may be inaccurate
• Some group members may be intolerant of medication use
• Commitment to the process is difficult if you disagree with idealogies behind the 12 steps (powerlessness, relinquishing control to higher power, etc.)
• Many group participants have severe emotional problems themselves, outside relationships should probably be avoided

Attendance of 12 step groups should be balanced with other activities to avoid becoming overly dependent on the group.

Source: http://addictions.about.com/od/overcomingaddiction/gr/12step.htm

There are many interesting articles that discuss various controversial aspects of AA and offer alternatives:

For Women, The 12 Steps Don't Always Work

Alcoholics Anonymous Effectiveness: Faith Meets Science

Medications

The use of medication to treat alcohol abuse is a subject of controversy, but some have proven relatively effective in managing cravings and reducing relapse.

APPROVED

Antabuse

Used to aid with initial abstinence; will make the user sick if they drink. One of the biggest drawbacks to this medication is non-compliance with actually taking the drug.

Naltrexone

Treats addiction during first 3 months; shown to decrease relapse by 50%-70% when combined with comprehensive treatment program. Drawbacks include: hard on liver, blocks effects of opioid pain medications (which may actually be desired if intended to reduce opiate addiction relapse).

Acamprosate

Has shown modest success in lowering cravings.

Chlordiazepozide

Treats withdrawal symptoms.

OFF-LABEL

Clonidine

Topiramate (and other anti-seizure medications)

Blocks dopamine, preventing alcohol from stimulating reward/reinforcement pathway.

Baclofen

A GABA receptor agonist.

Nalmefene

An opioid antagonist.

More information can be found here: http://www.casacolumbia.org/upload/2012/20120626addictionmed.pdf

Source: Inaba, D. S., & Cohen, W. E. (2011). Uppers, downers, all arounders: Physical and mental effects of psychoactive drugs (7th ed.). Medford, OR: CNS Productions, Inc.