This article was published in the BC Psychological Association’s journal.
James Ligertwood, ICADC, ICCS &
Dr. H. Elise Reeh, Registered Psychologist
It was all quite familiar. Jeff* was in a hotel room with a prostitute to use some crack cocaine. He laid out his drugs and stuffed steel wool into the pipe with a practiced hand. Three or four beers had provided the lightheaded glow he needed to move ahead. Somewhere in his frenzied mind he knew it was all a bad idea, but he was single-minded in doing what he wanted to do this minute. He held the pipe to his lips, lit the bowl’s contents, and heard the familiar crackle of the flame as he inhaled deeply, drawing the acrid smoke into his very soul. The effect was immediate: a feeling of power, euphoria and, above all, relief from whatever demons had possessed him to make the robotic decision to return to crack cocaine. He passed the pipe to his companion while he enjoyed the pleasure of the moment. Jeff had completed treatment just over eight months ago and he had been abstinent until then.
Relapse does not begin when the addict uses drugs; it ends there. An examination of Jeff’s relapse reveals a number of high risk situations that led up to it. Marlatt, Parks, & Witkiewitz, (2002) state that Relapse Prevention Therapy’s (RPT) main goal is to extinguish the strong and over-learned bond between seeking pleasure and/or pain reduction and the client’s drug or behavior of choice (such as over-eating, gambling etc.). Once clients develop an understanding of their unique circumstances (i.e. triggers and high risk situations) and they develop coping methods to address these triggers and high risk situations, protracted practice, determination, and social support, usually with a lot of lapses and relapses along the way, can lead to long term abstinence (Kadden, 2002).
Let’s look at what led up to Jeff’s relapse. He believed he had done everything right: he avoided his old haunts and addict-friends, he attended counseling, and he went to some fellowship meetings. He became unusually confident in his ability to stay clean. For example, he had happily remarked weeks before his relapse that he had not craved cocaine for some time and that he would never use again. Besides, he stated, his addiction had almost killed everything he held dear to him. This overconfidence is a common high risk factor because it can lead to complacence.
Weeks before his relapse, there were several other high risk factors that Jeff did not address. For example, he experienced subtle changes in his thoughts and feelings (of which he was only vaguely aware). He started to value his recovery activities less. His levels of stress, anxiety, and depression had been subtly increasing. Stress paired with not coping well is one of the most critical high risk factors when in recovery. Jeff frequently felt stressed at work. He was irritable with his wife. He had been retreating to his office so he could be alone and so that he could avoid talking about the issues that were troubling him. He ceased talking about his thoughts, feelings, and actions. Instead, he chose to emotionally isolate himself from the people who could help him while entertaining an unrealistic expectation of happiness without doing anything to make that so. He also was not realistically working toward a more balanced life. Finally, when his wife pointed these things out to him, he became defensive and stormed out of the house in anger. It was apparent to others, but not to Jeff, that his control over his addiction was slowly dissolving.
Jeff then began to secretly indulge in visits to the casino. He started eating poorly and he felt tired most of the time because his sleep was now sporadic and marked with disturbing dreams. His daily routines had become haphazard and he acted as if he no longer cared about himself or his sobriety. He started lying to his wife, friends, and family. He started rationalizing drinking and using drugs by thinking of it as an experiment and that surely after his long period of abstinence he would be able to just indulge once and then to control it afterwards.
At this point, many addicts entertain positive outcome expectancies such as thinking drugs will make them feel better (which is true in the short term but relapses can be devastating in the long term). They focus on the positive aspects of their drug use and they deny the negative consequences (Marlatt et al., 2002).
After the relapse, Jeff and his counselor tried to make sense of his relapse by using Marlatt et al.’s strategies (as follows). His counselor helped him to overcome the abstinence violation effect (AVE), which involved Jeff feeling shame and guilt about the relapse, thinking he was beyond help, and that the relapse was due to static internal factors. Left unaddressed, this AVE could set Jeff up for further relapses. Instead, Jeff and his counselor reframed the relapse as a learning experience that will increase his eventual success in abstinence. His counselor normalized the relapse as he found that about 90% of his clients had at least one relapse. His counselor helped Jeff to build his self-efficacy (his belief that he is able to recover). They reviewed Jeff’s thinking errors that glorified his drug use and that allowed him to only focus on the positive aspects of his drug use while ignoring the negative experiences. His desire to indulge was also related to his unbalanced lifestyle in which he worked long hours and spent increasingly less time doing the activities he needed to prevent relapse.
Jeff’s story highlights the need for ongoing attention to the addiction for long after abstinence is achieved. Post-acute withdrawal symptoms are invariably triggered by stress and can last for years. Therefore, it is crucial that recovering addicts have a network of support in place when these symptoms appear. Support systems may include knowledgeable family members and friends, counselors, and sponsors. In addition to good social support, the recovering person needs well-practiced coping skills such as venting to social support, mindfulness, meditation and exercise (Witkiewitz & Marlatt, 2011). Becoming involved in pro-social activities such as volunteering, team sports, and attending support groups (such as AA or NA) can also contribute to leading a balanced lifestyle which reduces the risk of stress and relapse as well as fills the addicts’ time that was formerly spent on pursuing and using substances (Kadden, 2002).
*We based Jeff’s story on common client experiences. We chose the name as an example and therefore it was not the name or the story of an actual client. Any resemblance to an actual client named Jeff or otherwise is coincidental.
Kadden, R.M. (2002). CBT for Substance Dependence: Coping Skills Training. Available at http://www.bhrm.org
Marlatt, G.A., Parks, G.A. & Witkiewitz, K. Clinical Guidelines for Implementing Relapse Prevention Therapy, 2002. Available at: http://www.bhrm.org/guidelines/RPT%20guidelines.pdf
Witkiewitz, K. & Marlatt, G.A. (2011). Behavioral Therapy across the Spectrum, Alcohol Research and Health, 33, 313-319.
James Ligertwood has been an addiction counselor and clinical supervisor for the past 20 years. He is currently an outpatient counselor with a Salvation Army agency in Chilliwack, BC. He is an Internationally Certified Alcohol and Drug Counsellor (ICADC) and an Internationally Certified Clinical Supervisor (ICCS).
Dr. H. Elise Reeh has been a Registered Psychologist since 1996. She has a private practice in Mission BC. She sees adult clients for a variety of issues including substance abuse.