April 18

A Theory of Addiction Relapse Prevention

Posted by William Berry | Filed under Articles | No Comments

When I first decided to write an article about relapse prevention, I felt anxious about what to include or exclude. I initially thought about all the material I have on relapse prevention, and how I could integrate it into one article. The truth is, I consider everything I do in treatment as relapse prevention, with the exception of helping someone get into treatment when they are actively using.

Over the course of my career I have written my own outlines for educational groups and the handouts, which I recently turned into a workbook being edited for publishing. The first educational group in my curriculum is on the disease concept. I believe all relapse prevention starts here. Accepting that one has a disease, however it was contracted, through genetics, social influence including but not limited to simple habit, or as a result of trauma, is the building block for recovery.

I next focus on how this disease affects the perception of reality of an addict. Simply, addicts are subject to cognitive distortions which alter the perception of reality. The most prolific example of this is when an addict or alcoholic is in denial. Reality demonstrates they have an addiction. Others who have an objective perspective are able to see this clearly. Yet the addict believes that their problems are the result of many things, none of which are their drinking or using excessively. Of course this is not the only distortion. Others that are common include rationalizing, justifying, minimizing and projecting. I would refer anyone interested in further explanation of distortions common to addicts to Abraham Twerski’s book “Addictive thinking: Understanding Self Deception.”

The next step in my curriculum focuses on teaching client’s to challenge thinking. Since an addict has these distortions, challenging them becomes imperative to recovery. Besides typical cognitive distortions mentioned above, a relapse, and the thinking that leads to it, begins before the actual consumption of a substance. Terence Gorski has described the “Phases and Warning Signs of Relapse” in both books and pamphlets. One of the common factors in his theory is the change in thinking that occurs as one heads for relapse. Again, this reiterates the importance of challenging one’s thinking.

The true question however, is how does one identify when their thinking is distorted, or when it is setting them up for a relapse. The 12 step programs discuss “stinking thinking” and it is common to hear there or in treatment centers “that’s your addiction talking.” But it is difficult for a person to identify when his or her own thinking is heading in a dysfunctional fashion.

When I discuss relapse prevention in educational groups, I begin with the basics of relapse prevention: complete abstinence, (no use of mood altering chemicals), attending 12 step meetings as frequently as recommended for the length of sobriety, sharing in the meetings, working the steps, working with a sponsor and, if in formal treatment, a therapist, using sober support, and applying knowledge gained in treatment to recovery. Additionally, avoiding people, places, and things that are associated with addiction and adding new people, places, interests and hobbies is important to sustaining recovery.

Normally, I follow the basics with what I call the three essentials, and what 12 step programs assert as cornerstones of their programs. I also believe these are essential to answering the above question, “how does one identify when their thinking is distorted, or when it is setting them up for a relapse?” The three essentials are Honesty, Openmindedness, and Willingness.

Honesty includes the ability for one to be honest with oneself, having attained the ability to recognize and challenge rationalizations, justifications, and other cognitive distortions, as well as recognize and share emotions. It also includes the ability to be open and forthcoming with others, especially those identified as confidants. It includes the ability to question oneself and especially the motivations for actions in any given situation. It also includes the ability to get past facades or self-projections which are designed to control how others perceive the individual; and share the true, natural, authentic self with another.

Open-mindedness is an essential in recovery and relapse prevention. It includes humility, the ability to humble oneself truly and accept that one may not know what is best at any given moment. It is the ability to truly accept feedback, to be fully aware that others’ perceptions may be more accurate than one’s own perception. This is of utmost importance when considering “The Phases and Warning Signs of Relapse” I mentioned earlier. Many ask during and at the conclusion of that educational topic, “What do I do if I’m unaware that I am in a relapse phase?” The only answer to that question is to become aware that you are in a relapse phase. How does one become aware? This question has two possible answers. The first is honest self-evaluation, including the ability to objectively look at one’s own thinking (I will speak more of this a little later). This alone is often not enough for even the most diligently self-evaluative person. That is where open-mindedness comes in: the need to be humble, and evaluate the feedback received from others, without becoming defensive.

The third foundation is Willingness. An individual, being honest with self and others, open-minded to others’ feedback, must be willing to make the necessary changes in thinking and behavior. This may seem simple. But to borrow a saying from AA, “this is a simple program, not an easy one”. Addicts often want the way they feel to change, but when told what they need to do to facilitate the change; they find excuses or otherwise balk at the necessary action. Willingness is therefore essential to prevent a relapse.

I will now discuss the importance of being able to step back and look at one’s thinking objectively. This is a subject which is receiving attention in journal articles of late. Without even searching the subject, I have read two articles about it. One was entitled “Mental Balance and Well Being: Building Bridges Between Buddhism and Western Psychology” by B. Allan Wallace and Shauna Shapiro and was in the journal “American Psychologist, V.61, n. 7, October 2006. Another was given to me by a colleague after we discussed this topic casually. It was entitled “The Application of Mindfulness-Based Cognitive Interventions in the Treatment of Co-Occurring Addictive and Mood Disorders” and was written by Kimberly Hopes PsyD.

This topic also reminds me of a group session I was having one night. In attendance were three male clients and myself. These three clients had all been inpatient together, and were now in the Intensive Outpatient Program. There length of clean time varied minimally in the grand scheme of things, but to them it may have seemed longer. In the course of the discussion, this topic came up. All three had discussed incidence where they had been able to step back from the emotional intensity of a situation. They were focusing on how they reacted differently in this situation then in the past. I raised how they had all been able to step back from their thinking and emotional states. I also pointed out how in early recovery when experiences are new in sobriety; this ability is sometimes easier than later in recovery. I posed the question “how do you plan to keep this ability in later recovery?” The replies were similar. The responses centered on the need to remain aware of their thinking, to step back and remember they did not have to engage in the emotional events. They discussed how realizing they had power over their thinking, at least the thoughts following their automatic thoughts which lead to their perceptions, helps them to step back and look at situations objectively.

This is the heart of mindfulness. This is the heart of Eastern philosophy. And it is extremely beneficial to recovery. It leads to the ability to step back from emotionally charged situations. It leads to the ability to recognize the mood as transient. This allows the urges usually associated with emotionally charged situations to lose power. And this leads to a more successful recovery from addiction.

One way to attain this mindfulness is through one’s chosen spirituality. This can be through simply turning one’s will over, or through meditation. Meditation, another topic getting attention in journal articles of late, has been proven to be effective in improving mood even for a novice to meditating. As one religious leader once told me, “prayer is asking God, meditation is listening for the answer.” Another way to attain it is through cognitive challenging, although, and despite my reliance on cognitive therapy, I find it less effective than either the spiritual component or meditation.

In conclusion, reducing relapse is a daunting task. It begins by following the behavioral suggestions for recovery. Being honest, open-minded, and willing would be cognitive changes, as they involve a change in perspective. This provides a strong foundation. Mindfulness adds another tool, one that is receiving accolades and attention these days, but has been around for centuries. Besides relapse prevention, it offers a more fulfilling recovery. I look at the educational portion of my job as helping clients understand they have a disease. This disease affects the way they think. If they become able to step back from their thinking and challenge it, they are beginning the objectivity that assists in recovery. Moving further into mindfulness promotes and deepens recovery. And finally, everything in recovery is about relapse prevention.

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This entry was posted on Friday, April 18th, 2008 at 4:22 PM and is filed under Articles. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

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