03/4/16

Managing Stress in Recovery

© marigranula | 123rf.com

© marigranula | 123rf.com

People in recovery are particularly vulnerable to stress. In Using Stress Management in Relapse Prevention Therapy (RPT), Terence Gorski pointed out that effective stress management was not only critical for avoiding a resumption of drinking or drugging in the first two weeks of abstinence, but it was also important for individuals in recovery “to learn how to recognize their stress levels and use immediate relaxation techniques to lower their stress.”  Regular, heavy use of alcohol and drugs will likely have toxic effects on the brain, and in turn will create symptoms that cause stress and interfere with effective stress management.

The role of stress sensitivity in addiction and relapse has received a well-deserved amount of attention in the professional literature. Another article here, “Stress Sensitivity in Addiction and Relapse,” looked at some of the findings of Mary Jeanne Kreek and George Koob on the topic. A third researcher who has done extensive research into stress and its influence on addiction is Rajita Sinha of the Yale School of Medicine. You can watch her lecture on: “Clinical Neurobiology of Stress and Addiction” on YouTube. You can also read a couple of her published articles, “New Findings on Biological Factors Predicting Addiction Relapse Vulnerability” and  “Chronic Stress, Drug Use, and Vulnerability to Addiction.”

In her “New Findings” article, Sinha presented data that demonstrated high drug cravings are related to both stress and drug cues in addicted individuals when they are compared to social drinkers. The research findings indicate: “that alterations in physiological stress responses are associated with high levels of stress-induced and cue-induced craving and distress states.” These alterations were marked by increased emotional stress, heightened craving in abstinent addicted individuals compared to social drinkers. Refer to Figure 2 in the article for a chart comparing the findings. Sinha also noted a series of stressors that are associated with addiction vulnerability—the risk of developing an addiction and the risk of relapse. Table 1 in her article summarizes the types of life events chronic stressors, etc. associated with addiction risk.

The types of adverse events significantly associated with addiction vulnerability were parental divorce or conflict, abandonment, forced to live apart from parents, loss of child by death or removal, unfaithfulness of significant other, loss of home to natural disaster, death of a close one, emotional abuse or neglect, sexual abuse, rape, physical abuse by parent, caretaker, family member, spouse, or significant other, victim of gun shooting or other violent acts, and observing violent victimization. These represent highly stressful and emotionally distressing events, which are typically uncontrollable and unpredictable in nature.

An early recovery issue common to both alcoholics and addicts is Post Acute Withdrawal (PAW). Gorski described PAW as “a bio-psychosocial syndrome that results from the combination of brain dysfunction caused by alcohol and drug use and the stress of coping with life without drugs or alcohol.” PAW disrupts the person’s ability to think clearly, to manage feelings and emotions, as well as to manage stress and self-regulate behavior.

Stress negatively effects brain function in early recovery. As the level of stress goes up, the severity of PAW symptoms increase. And as PAW symptoms get worse, individuals in recovery begin to lose their ability to effectively manage stress. The result is that they are in regular, constant states of high stress that bounces them back-and-forth between emotional numbness and emotional overreaction. High stress then becomes linked with cravings because during active drug use, the addict or alcoholic self-medicates with alcohol or drugs. “So one of the first steps in managing craving is to learn how to relax and lower stress without using alcohol or other drugs.”

The severity of PAW depends upon the severity of brain dysfunction caused by addiction and the amount of stress experienced in recovery. It’s not practical to remove yourself from all stressful situations,  so you need to develop ways to handle stress when it occurs. “It is not the situation that causes stress; it is your reaction to the situation.” Gorski then proceeds to describe a simple tool to monitor stress called the Stress Thermometer. Then he described an immediate relaxation technique called Relaxed Breathing to help you noticeably lower your stress in two or three minutes.

In his Relapse Prevention Therapy Workbook, Gorski said the goal is to keep your stress level in the functional range of the Stress Thermometer, between 4 and 6. If your stress drops below a 4, your mind will wander and you won’t be able to stay focused. If your stress level gets to above 6, you will begin to lose focus; then become driven and defensive. “The higher your stress level goes the more problems you will experience.” If your stress level reaches 9 or higher, you may start to use automatic survival defenses such as fight (getting angry, belligerent, or violent), flight (mentally checking out or leaving; not returning), or freezing (becoming compliant; becoming immobilized in whatever situation you find yourself).

Look at his article linked above for a detailed description of the Stress Thermometer. You can also find a graphic rendition of it in another one of his articles, “Stress Self-Monitoring and Relapse.” Gorski commented that when measuring your personal stress, you’ll notice that it is a combination of three things: the intensity of the stressor, your ability to cope with or handle the stressor and your level of awareness while you are experiencing the stress. He added that it was possible to score yourself very low on the stress thermometer even when your stress is quite high.

This happens because you are distracted and involved in something else, like managing the crisis causing your stress. Or because your stress is so high, you are emotionally numb and don’t realize what you are feeling. Another possibility is that you have lived with such high stress for such a long time that you consider it normal. A final possibility is that you have trained yourself to ignore your stress.

The first step in learning to manage your stress is to learn how to recognize and evaluate your stress level through body awareness. Then you learn how to quickly get back to a low stress level by using the Relaxed Breathing Technique. Again, turn to Terry’s description monitoring your stress through body awareness and reducing your stress through Relaxed Breathing in the above linked article.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s Blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.

11/9/15

Managing Your PAWS

© eriklam |stockfresh.com

© eriklam |stockfresh.com

The presence of some brain dysfunction is common with recovering alcoholics/addicts. Some studies have suggested that 71% to 96% of individuals perform in the impaired range of various psychological tests. McGrady and Smith in a 1986 article, “Implications of Cognitive Impairment for the Treatment of Alcoholism,” said: “Given the bulk of evidence, it is reasonable to conclude that cognitive impairment is a concomitant of alcoholism.” An “Alcohol Alert” by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicated that even mild to moderate drinking could affect cognitive functioning. But although it stood to reason that cognitive impairment could impede recovery, “evidence has not conclusively shown this to be the case.”

However, a study by Fein et al., “Cognitive Impairments in Abstinent Alcoholics,” published in Addiction Medicine found: “The most significant determinant of the presence of cognitive deficits in persons recovering from alcoholism is the time elapsed since their last drink.” When the time period was controlled, different patterns emerged. They classified the abstinence time into three time periods. The acute detoxification period could last as long as the first two weeks of abstinence. The intermediate abstinence period was from the end of the detoxification time through the first two months. The long-term abstinence period extended from two months to five years of abstinence. The general pattern of deficits in these three time periods is shown within Table 1 taken from Fein et al.

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Alcohol use has well-documented effects on attention, concentration, reaction time, motor coordination, motor speed, judgment, problem solving, learning and short-term memory. Because these impairments are substantially reduced with detoxification, neuropsychological testing during this time period is of little value. “It is the residual deficits in patients following detoxification that are relevant to the diagnosis of cognitive impairment.”

Fein et al. stated that sensitivity to the possibility of cognitive impairments in abstinent alcoholics was essential to informed treatment planning. Individuals with deficits to learn new information were at a disadvantage in intensive treatment programs. They could be seen as “unmotivated” or “not ready to stop drinking” rather than “impaired.” They suggested early treatment focus on enforced abstinence and be supportive, rather than make the patients learn new material or think analytically about their experience. As cognitive functioning improves, these patients may begin to participate in the more educational and insight-oriented aspects of treatment.

We note that the Alcoholics Anonymous program is appropriate to the cognitive limitations of newly abstinent alcoholic persons. The focus in Alcoholics Anonymous is on maintaining abstinence from alcohol within the context of acceptance and support. New initiates are told to come to as many meetings as possible (“90 meetings in 90 days”), with- out an expectation that they become fully indoctrinated into the culture of the program (“fake it until you make it”). Indeed, during the initial period, the emphasis is on behavioral change rather than on understanding or a change of attitude.

The apparent discrepancy between the NIAAA statement and the Fein et al. study may be explained by an observation made by Terence Gorski of how symptoms of post acute withdrawal (PAW) associated with the brain dysfunction from alcohol/drug use may contribute to many cases of relapse. According to Gorski, “Post acute withdrawal is a group of symptoms of addictive disease that occur as a result of abstinence from addictive chemicals.” Too often these “sobriety-based symptoms” of alcoholism and drug addiction are neglected or ignored. See “Recognizing Your PAWS” for more information on PAW symptoms. Or you can read Gorski’s Comprehensive Guide to PAW here.

PAW symptoms are not the same in everyone. There can be a wide variance from person to person in how severe they are, how often they occur and how long they last. Gorski suggested there were four patterns in PAW symptoms. If they get better over time, that is a regenerative pattern. If they get worse, he says it is degenerative. If it stays the same, that is a stable pattern. If it comes and goes, that is an intermittent pattern.

The most common pattern of PAW is regenerative and over time it becomes intermittent. It gradually gets better until the symptoms disappear and then it comes and goes. The first step is to bring PAW symptoms into remission. This means bringing them under control so that you are not experiencing them at the present time. Then the goal is to reduce how often they occur, how long the episode lasts, and how bad the symptoms are. You must remember that even when you are not experiencing them there is always the tendency for them to recur. It is necessary to build a resistance against them – an insurance policy that lowers your risk.

Stress triggers and intensifies PAW symptoms. Conversely, lower stress means less severe PAW. So learning to manage stress will help you manger PAW. Mindfulness meditation has been shown to be very effective in reducing stress levels. In How God Changes Your Brain, Andrew Newberg and Mark Waldman noted that animal studies have shown how mild, short-term or chronic stress impairs memory by disrupting dendritic activity. “If the situation that is causing the stress is removed, function is restored.” Intentional relaxation, as with deliberately scanning each part of your body to reduce muscular tension and fatigue will not only relieve bodily tension, it will interrupt the release of stress-stimulating neurochemicals.

When all is said and done, you are responsible for protecting yourself from anything that threatens your sobriety or anything that triggers post acute withdrawal symptoms. Reducing the stress resulting from and contributing to the symptoms of post acute withdrawal must be of prime consideration for you. You must learn behavior that will protect you from the stress that might put your sobriety in jeopardy.

Good nutrition plays a role in stress reduction and managing PAW. Gorski suggests a high protein, complex carbohydrate meal plan. Eat three well-balanced meals daily. Eat three nutritious snacks to stave off hunger, which is a stress producer. Potato chips, candy and other high calorie low nutrient foods are no-nos. Avoid foods high in sugar and limit your caffeine intake. Also use multiple vitamins, vitamin B-12 and broad-spectrum amino acids.

Regular aerobic exercise helps to reduce stress. “Many recovering people will testify to the value of exercise in reducing the intensity of PAW symptoms. After they exercise they feel much better, find it easier to concentrate and remember, and are able to be more productive.” Exercise will stimulate the release of neurochemicals that help relieve pain, anxiety and tension.

In The Emperor’s New Clothes, Irving Kirsch reported that studies of physical exercise as a treatment for depression have shown several surprising findings. Exercise is more beneficial for moderate to severe depression than it is for mild to severe depression. These benefits seem to be long lasting, if the person continues to exercise regularly. Twenty minute three days per week is enough to produce the antidepressant effect. But Gorski suggests daily exercise because of its added value in reducing stress.

According to Gorski, spirituality is an important tool in managing PAW symptoms. “Through spiritual development you can develop new confidence in your own abilities and develop a new sense of hope.” Using the principles of the AA/NA program to increase your conscious contact with your higher power is an important part of this spiritual development. You simply have to be open to the possibility of a Higher Power and be open to experimenting with a form of communication with that Power. There isn’t a required structure to that communication.

Try reading Greenberg’s and Waldman’s book, How God Changes Your Brain for suggestions on how meditation can be practiced from a nonreligious point of view. Greenberg has done research that has showed neurological changes in the brains of praying nuns that was nearly the same as that in the brains of Buddhist monks meditating. This evidence confirmed their hypothesis that the benefits gleaned from prayer and meditation may have less to do with a specific theology “than with the ritual techniques of breathing, staying relaxed, and focusing one’s attention upon a concept that evokes comfort, compassion, or a spiritual sense of peace.”

A final area in managing PAW is living a balanced life. “It means your are healthy physically and psychologically and that you have healthy relationships.” You have time for your job, your family, and your friends, as well as your own growth and recovery. It also means wholesome living. It needs a strong social network that nurtures you and encourages a recovery-oriented lifestyle. The two primary goals in any person’s recovery are to establish and maintain a recovery-oriented lifestyle and to establish and maintain a sober support system.

It [balanced living] means having a balance between work and play, between fulfilling your responsibilities to other people and your need for self-fulfillment. It means functioning as nearly as possible at your optimum stress level, maintaining enough stress to keep you functioning in a healthy way and not overloading yourself with stress so that it becomes counterproductive. With balanced living, immediate gratification as a lifestyle is given up in order to attain fulfilling and meaningful living.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s Blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.

11/2/15

Recognizing Your PAWS

© willeecole |stockfresh.com

© willeecole |stockfresh.com

I knew a woman who was staying in a six-month drug and alcohol residential treatment center. She began to forget where she left her cigarettes. At first, it was just frustrating and kind of embarrassing. She would check the cafeteria; the living room; the group room. She’d go upstairs to her bedroom. She’d ask other residents if they saw her cigarettes. She’d check outside at the picnic table where the residents smoked. After awhile, she began to worry that she was losing her mind and even became fearful she could end up in a mental hospital.

There was a guy in his thirties who worked out with free weights in his basement. He’d been doing this since he began playing sports in his teens, but got away from it when his drinking became more important. After a few weeks of abstinence, he decided to start lifting again and went down to his basement. He started out with a fairly light amount of weight and intended to do some bench presses. But he almost dropped the bar on his windpipe. He spent a few days worried that his drinking had physically damaged him to the point that he didn’t have the strength and coordination to lift weights.

Both of these individuals were in the early stages of recovery and both were experiencing problems with post acute withdrawal (PAW) symptoms. Learning about PAW helped each of them see that they weren’t losing their mind, nor had they caught some degenerative muscle disease from their drinking and drug use. The material on PAW that I’ve found to be most helpful is that published by Terence Gorski. He discusses PAW symptoms and how to manage them in Staying Sober, and Straight Talk About Addiction, which are available through Amazon or Herald House Independence Press. You can even find a free comprehensive guide on PAW, excerpted from Staying Sober, on Terry Gorski’s Blog.

“Post acute withdrawal is a group of symptoms of addictive disease that occur as a result of abstinence from addictive chemicals.” PAW symptoms can appear as early as 7 to 14 days into abstinence—just as the person stabilizes from any acute withdrawal symptoms they might experience. They are a combination of the damage done to the nervous system from alcohol and drugs and the psychosocial stress of now trying to cope in life without drugs and alcohol. Gorski said there are six major types of PAW symptoms: 1) inability to think clearly; 2) memory problems; 3) emotional overreactions or numbness; 4) sleep disturbances; 5) physical coordination problems; and 6) stress sensitivity. The PAW Comprehensive Guide on Terry Gorski’s Blog has a helpful discussion of each of these PAW symptoms.

The symptoms of PAW typically grow to peak intensity over three to six months after abstinence begins. The damage is usually reversible, meaning the major symptoms go away in time if proper treatment is received. So there is no need to fear. With proper treatment and effective sober living, it is possible to learn to live normally in spite of the impairments. But the adjustment does not occur rapidly. Recovery from the nervous system damage usually requires from six to 24 months with the assistance of a healthy recovery program.

Gorski noted that research has also shown that PAW symptoms can go through cycles or crop up without any triggers or stressors going on. The classic pattern of slips that seem related to PAW cluster around sobriety dates—30, 60, 90 days; 6 or 12 months. They can occur without an obvious pattern or trigger. People in recovery from long-term opiate or stimulant use have reported times of PAW symptoms for no apparent reason for up to ten years after their abstinence. “Individuals who intend to have consistent long-term recovery must learn to recognize these symptoms and learn how to manage them.”

A helpful tool to do this can be found in Gorski’s Staying Sober Workbook, the Post Acute Withdrawal (PAW) Self Evaluation. I encourage people in early recovery to make a copy of their PAW self evaluation, date it and then hold on to it. If they later experience a time when PAW symptoms reemerge, they can compare it to the earlier time when PAW was in full bloom. This can be helpful in judging just how dangerous the most recent time of PAW is to their recovery. If a stressor after one year of abstinence can trigger PAW symptoms at the level of intensity you were having with only two or three months of abstinence, that’s crucial information for someone in recovery to have.

The booklet The Relapse/Recovery Grid by Gorski is an excellent summary of both his Developmental Model of Recovery and the Relapse Process. There is a handy grid that provides you with a comparison of both the Developmental Model of Recovery and the Relapse Process. I’ve found this grid to be very helpful when doing psycho-educational presentations on both recovery and relapse. One of its features relevant to our discussion here is how the above noted PAW symptoms are the heart of the initial stage of the Relapse Process, Internal Dysfunction. Here is the introductory paragraph on Internal Dysfunction:

When under high stress, many recovering people begin to have difficulty thinking clearly, managing feelings and emotions, and remembering things. One of the main culprits leading to these problems appears to be a tendency to overreact to stressors. Scientists call this neurological augmentation. Many recoverying people refer to this as stress sensitivity. People perceive light to be brighter, sound to be louder, and touch to be intrusive. They startle easily and quickly, and become distracted by things that happen around them. Eventually, the ability to sleep restfully is disrupted. This heightens stress and fatigue to the point where people become accident-prone.

This illustrates the importance for someone to recognize, monitor and manage PAW symptoms throughout recovery. The person who can effectively do so increases the likelihood of never lapsing or relapsing into active drug or alcohol use again because they are neutralizing a relapse in its initial phase. Also look at “Managing Your PAWS.”

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s Blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.

09/7/15

Preventing and Stopping Cravings

© Boris Ryaposov | 123rf.com

© Boris Ryaposov | 123rf.com

Not all addicts and alcoholics struggle with cravings in recovery. And not all addicts and alcoholics experience them with the same intensity. But knowing how to recognize the sets ups and triggers for a craving are crucial skills for those in recovery who do experience them. Otherwise, it’s like living through a drug and alcohol-themed version of Groundhog Day.

On his blog, Terence Gorski described a three-stage model to manage cravings without them leading back to active drug or alcohol use. Two previous articles “Ready to Cope with Cravings” and “Getting Set to Cope with Cravings” reviewed the three stages of Gorski’s model to understand cravings. This final article of the three part series describes how to prevent cravings and stop them once they do occur.

Craving is not an inevitable process. They can be prevented if you follow a few simple guidelines. And they can be managed without a return to active drug use. Gorski suggested five preventive measures against craving.

  • First, develop and maintain a structured recovery program that keeps you in regular, continuous, daily contact with other recovering people.
  • Second, know what your triggers are. “Identify the things that activate the craving and learn how to cope with those triggers.”
  • Third, know and avoid your set-up behaviors; learn how to cope with them if you can’t avoid them.
  • Fourth, dismantle euphoric recall—intentionally include where the “fun” of the high will eventually lead you. Remember where it took you in the past.
  • Fifth, stop awfulizing sobriety and put an end to magical thinking.

Despite your best efforts, you may still experience cravings. Remember that they are a normal symptom experienced by most addicts in recovery.  While there are a fortunate few who have minimal or no problems with cravings in early recovery, they are the exception, not the rule. So if you have cravings, stop them from leading you back to active drug use by practicing a few simple steps.

  • First, recognize the craving. This may seem obvious, but sometimes the craving is mild and appears to be something you can “white knuckle” it through until it’s over. “Many addicts fail to identify mild craving as problematic and wait until they are full-blown, severe cravings before taking action.”
  • Second, don’t panic if you have one. Remember that cravings are normally experienced by addicts in recovery. It doesn’t mean you are doomed to resume active drug use or that you aren’t doing enough for your recovery.
  • Third, get away from where you are. A craving might be activated by an environmental trigger. You may have thought a situation wouldn’t be a trigger, only to discover once you are in it, that it triggers you. GET OUT OF THERE and go to “an environment that supports recovery.”
  • A fourth step you can take is to talk the craving cycle through with someone. “If you talk it through, you don’t have to act it out.” Honestly talking the process through from beginning to end can discharge the urge to use because you are mentally removing yourself from it. It’s like you have a video of the process that you are reviewing. You stop, rewind, fast-forward, and go frame by frame with the recording of what happened to discover the timeline and cause-and-effect chain reaction of what led to the craving.
  • Fifth, distract yourself. Divert attention from the craving by engaging in other productive, positive activities that require your full attention.
  • You could do some aerobic exercise, a sixth action step to cope with cravings. Aerobic exercise can stimulate brain chemistry that reduces cravings.
  • Seventh, you can try meditation or relaxation. Cravings are often intensified under high stress. “The more a person can relax, the mower the intensity of the craving.”
  • Eighth, you can eat a healthy meal to nourish your brain.
  • Ninth, remember they are time-limited and will eventually pass. Most cravings won’t last more than two or three hours. If you persist in the steps suggested here to the point of getting fatigued enough to fall asleep, many people wake up with the craving gone.

It is possible to understand drug craving and to learn how to manage craving without returning to use. A model that allows people to identify set-up behaviors, trigger events, and the cycle of craving itself, and intervening upon this process has proven effective in reducing relapse among addicts.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

08/31/15

Getting Set to Cope with Cravings

© Boris Ryaposov | 123rf.com

© Boris Ryaposov | 123rf.com

On his blog, Terence Gorski described a three-stage model for addicts and alcoholics to manage cravings without them leading back to active drug or alcohol use. The first stage of set-up behaviors was discussed in a previous article, “Ready to Cope with Cravings.” This article will review the next two stages, trigger events (The Set Stage) and the craving cycle (The Go Stage).

The Set Stage

There are four main triggers that can activate immediate, powerful cravings during the Set stage, according to Gorski. Thinking triggers arise out of the mind-set or pattern of thought that follows the person into early recovery. Abstinence doesn’t magically make them disappear. Feeling triggers often come from sensory cues—seeing, hearing, touching tasting or smelling something that reminds the person of their drug of choice. “It also results from experiencing feelings or emotions that were normally medicated by use.” Behavioral triggers stem from behaviors and rituals that were previously associated with drug use. Situational triggers include relationships or circumstances that used to be associated with using.

There can be some overlap between set-ups and triggers. What distinguishes them in the discussion by Gorski seems to be the ability of a trigger to activate the immediate experience of a craving cycle.

Euphoric recall or fantasy that continues unchecked could become a thought or feeling trigger. Listening attentively as someone describes his or her own struggles with past addictive behavior or current struggles with set-ups or cravings can lead to a thought trigger. Seeing movies that portray drug use can initiate a strong craving. Intravenous drug users can be triggered when their blood is drawn. Alcoholics can be triggered by hearing someone snap open a soda can.

Certain situations, rituals or behaviors that become associated with using can become behavioral or situational triggers. Think here about the principles of classical Pavlovian conditioning. One person I knew couldn’t listen to a certain CD, because he has regularly listened to it when he was high. Another individual discovered that sitting and thinking in a particular chair in their home was a trigger, because that was where she had sat when she drank. Another person avoided the cleaning supply isle in supermarkets because they had used chore boy scrubbers to make their crack pipes.

The often-repeated mantra to avoid People, Places and Things associated with addiction will include all the above categories of set-ups and triggers. But the nuance of addictive experience means that not every physical, psychological or social set-up is equally dangerous to all addicts and alcoholics. Not all thinking, feeling, behavioral or situational events will immediately trigger a craving cycle with all alcoholics and addicts. Not all People, Places and Things put addicts and alcoholics equally at risk of cravings or relapse. The failure to acknowledge this will potentially awfulize recovery (one of the psychological set-ups).

Using Gorski’s stages of set-ups and triggers, I’d suggest that any person, place or thing associated with addiction should be considered to be a set-up. Careful examination, discussion and analysis of these set-ups will determine whether they have a greater or lesser potential to become a trigger and activate a craving cycle for the individual. The earlier a person is in recovery, or the more stressful or unstable the life of a person with longer-term recovery is, the more careful they should be to avoid set-ups. The more stable the person’s life and recovery is, the greater nuance they can have in their exposure to set-ups. Any set-up that carries the potential to become a trigger for the individual should be avoided. The diversity of experiences when using, even among individuals with the same drug of choice, means that not every physical, psychological or social set-up is equally dangerous to all addicts and alcoholics.

The Go Stage

The third stage of craving is the actual craving cycle. Here the obsessive thoughts to use triggers a compulsive desire to get high, with physical cravings for the drug and then actual drug seeking behavior occurs.

When an obsession becomes activated, the person experiences a loss-of-control with their thinking. “Intrusive thoughts invade their mind and they can’t turn them off.” The obsession will quickly become a compulsion. Despite knowing it would be dangerous to use drugs, in a compulsion the person has an overwhelming urge to get high. This obsession and compulsion leads to full-blown physical craving, which can be quite powerful. The person may have a rapid heart beat, shortness of breath, perspiration; even an actual sense of tasting smelling, or feeling the drug they are craving.

Attempting to manage the cycle of obsession, compulsion and craving, the person begins active drug-seeking behavior. They might return to their old hangouts; call up old drug using friends. In other words, return to people, places and things associated with addiction. This exposure to more triggers intensifies the craving cycle. Ultimately, the person becomes overwhelmed with this cycle of obsession-compulsion-craving and they return to active drug use.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is the second of a three-part series on coping with cravings. The other two articles are “Ready to Cope with Cravings” and “Preventing and Stopping Cravings.” You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

08/17/15

Ready to Cope with Cravings

© Boris Ryaposov | 123rf.com

© Boris Ryaposov | 123rf.com

Terence Gorski described a three-stage model for addicts and alcoholics to manage cravings without them leading back to active drug or alcohol use. The first stage was what he called Set-Up Behaviors—“ways of thinking, managing feelings, and behaving that increase the risk of relapse.” The second stage was Trigger Events—“events that activate the physiological brain responses associated with craving.” The third stage was the Craving Cycle—“a series of self-reinforcing thoughts and behaviors that continue to activate and intensify the craving response.” For ease of remembrance, we will refer to the first stage as “Ready,” the second stage as “Set,” and the third stage as “Go.”

Within the Ready stage, Gorski described physical, psychological and social set-ups that can lower the individual’s resistance to craving. At the Set stage, he said there were four primary kinds of triggers that could immediately activate a craving: Thoughts, Feelings, Behaviors and Situations. The Go stage, what Gorski called the Craving Cycle, was obsession, compulsion, physical craving and drug-seeking behavior.

There is often a progression from Ready, to Set, to Go—but not always. For example, euphoric recall is one of the psychological set-ups within the Ready stage, but these memories can be powerful enough to immediately activate a craving cycle (the Go stage). Here the memory is a “thought trigger” in the Set stage, one that immediately triggers a craving. Conversely, sometimes there can be set-ups—say socializing with drug-using friends—that don’t trigger thoughts, feelings, behaviors or situations that lead to a craving cycle. But such “misses” can give a person a false sense of security about future opportunities within this kind of set-up. The next time, you may not be so lucky.

The Ready Stage

Physical Set-Ups

Gorski said there are five common physical set-ups for cravings. The first is Brain Dysfunction from Drug Use. “Mind altering drugs [including alcohol] damage the brain” when they are misused or abused.  I would add that all drugs with mind-altering properties should be included here. The obvious drug classes are the benzodiazepines and opioids. However, I’d also include the antidepressants and the antipsychotics.

Current antidepressant medications typically modify levels of serotonin (or sometimes norepinephrine) in the brain. Antipsychotics generally work by blocking a dopamine receptor referred to as the D2 receptor. This receptor has been suggested in research to be related to compulsive eating and cocaine abuse. Carleton Erickson, in The Science of Addiction, indicated there were fifteen separate receptor subtypes of serotonin involved in chemical dependence, and five separate dopamine receptor subtypes. Neurontin (gabapentin) effects levels of the neurotransmitter GABA, which is influenced by benzodiazepines. GABA dysregulation also plays a part in alcohol dependence. My point is not that all addicts should taper off of their psychotropic medication. But in learning to manage and cope with cravings, they should consider the potential influence of their medications.

The second physical set-up is poor diet. Simply put, “Recovering addicts are often nutritional disaster areas because they live on junk food and don’t know what a healthy meal is.” Gorski adds that many individuals have coexisting eating disorders.

A third physical set-up for cravings is the excessive use of caffeine and nicotine. Gorski noted how both caffeine and nicotine, which are low-grade stimulants, could increase the likelihood of having a craving.

The fourth physical set-up is a lack of exercise. “Regular aerobic exercise is a protective factor against craving.” It can reduce the intensity of cravings.

A fifth physical set-up is poor stress management. Stress management activities such as meditation, relaxation exercises, regular periods of rest, relaxation and sleep are all helpful ways to manage stress. When people do not manage stress appropriately in recovery, they set themselves up for cravings during the times of stress that often occur in early recovery.

Psychological Set-ups

Euphoric recall occurs when an addict “romances” past times of drug use. They remember and magnify the pleasurable experiences of past use, while blocking out the painful and unpleasant memories. Spontaneous recollection of past “fun” times is common. To avoid euphoric recall leading to a craving cycle, “play the whole tape.” Don’t stop at the fun times, intentionally add where the pain and unpleasantness of past use fits into the story.

Awfulizing abstinence is another set-up. Here the addict attends to all the negatives and perceived losses about getting sober, while blocking out thoughts of the benefits. This leads to a mistaken belief that “being sober is not nearly as good as using the drug.”

In magical thinking, the addict sees drug use as the solution to their problems. Gorski said this was a combination of euphoric recall (Remember how good using was) and “awfulizing” sobriety (how awful it is that I can’t use). I’d suggest that an individual is also in magical thinking when their using history has demonstrated a clear inability to control drug or alcohol use, but they continue to harbor thoughts that when XYZ happens, they could try social or controlled using again.

This will lead to empowering the compulsion. The person exaggerates the power of the compulsion by telling themselves there is no way they can resist the craving; they can’t stand not having the drug. I’ve seen a subtype of this psychological set-up where the person will convince themselves they wouldn’t be able to resist the compulsion to use again if “X” disaster or crisis happened to them.

Gorski sees the psychological set-ups listed above as leading to the fifth and final one of denial and evasion. Here the addict rejects or denies that their actions could be setting themselves up to have a craving. They may deny that they need the help of a recovery program or treatment. “This denial does not go away simply because they are not using the drug.” Because denial is largely an unconscious process, many addicts believe they are doing the best they can; that they are making the right decision for their life and recovery when, in fact, they aren’t.

The stress of the instability and unmanageable circumstances that often occur in early recovery could lead to this as well. Awfulizing the obligations of early recovery or their lives, such as time away from work and family for treatment or meetings, possibly changing jobs or colleges, fear of financial consequences from not working, etc., can lead to this set-up.

Social Set-Ups

Socializing with drug using friends can be a stumbling block for addicts. Trying to negotiate abstinence without losing the ability to go around certain people who they used to drink and drug with is a major problem for some people. A potential loss of the relationship seems unthinkable at the time. Even when the active user voices support of the individual’s desire to establish and maintain abstinence, the contact may not be a good idea. For one thing, knowing the person is high, or has drugs close by can be a trigger for craving.

One of the reasons that an addict, particularly in early recovery, is drawn to socialize with their using friends is the desire to be with other people who understand them—how they think and what they struggle with. This is why social isolation is so dangerous for someone in recovery. This also points to a couple of the benefits to active participation in AA or NA—these are places where the person can share their fears, doubts and struggles without fear of rejection. And they can form new friendships with people who can relate to how they think and feel.

When open and honest self-disclosure is replaced by superficial communication, the person in recovery gets into trouble. They neutralize another benefit of active participation in self-help groups—the ability to get feedback and reality checks from others who understand how they think and feel about an issue. The lack of honest, heart-felt communication with other people who understand addiction is another social set-up.

If the above lack of honest sharing with others continues, it can lead to isolation from other people in recovery. This can happen through decreased meeting attendance and/or avoiding sober social situations with other recovering addicts. Another contributing factor here is if conflict of some sort occurs and becomes a justification for why the person avoids a particular meeting, or why honest sharing of what they are struggling with is not talked about. Unresolved conflict is another social set-up.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is the first of a three part series on coping with cravings. The other two articles are “Getting Set to Cope with Cravings” and “Preventing and Stopping Cravings.” You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

03/2/15

Pulling the Addiction Trigger

© Imageegami | Dreamstime.com

© Imageegami | Dreamstime.com

When you pull the addiction trigger, the disease of addiction fires off addictive thinking, automatic addictive or drug seeking behavior, and a craving or urge that pulls you toward high risk situations. (Terence Gorski)

The term “trigger event” is used to describe what turns on the addictive thinking, drug seeking behavior, or the craving (a strong need or drive) to be involved in high risk situations (See “The Yin-Yang of High Risk Situations”). Using the metaphor of a loaded gun, Gorski said addiction in early recovery is very much like holding a loaded gun—with a hair trigger.

The problem is that events and circumstances act as powerful triggers for some people, while they have no effect on others. What can be even more confusing is that some days a circumstance can activate a powerful trigger. But on other days the same situation does nothing to pull the trigger and activate the craving.

Mistakenly, triggers are often seen as only external to the person. So the focus in managing triggers becomes one of identifying and avoiding external situations related to drug use and drinking. But triggers can be internal as well as external. Gorski defined a trigger event as “any internal or external occurrence that activates a craving (obsession, compulsion, physical craving, and drug-seeking behavior).” By internal occurrences he means thoughts or feelings. External occurrences involve the five senses: sight, sound, smell, taste and touch.

For these events to become triggers, they have to be connected to the person’s use of alcohol or drugs. The trigger is stronger if the event happened just before or while using. This is what makes needles, when drawing blood, a trigger to the IV drug user. Years ago I knew someone who couldn’t listen to “The Wall” by Pink Floyd in early recovery because he always did so before when he was high.

Gorski then said there were three phases in “disempowering” a trigger. Phase 1 was Avoidance. Here the person is to make a list of the most powerful triggers associated with his using and avoided them. The ubiquitous recovery mantra to avoid people, places and things (PPT) associated with addiction fits here.

The second phase was to gradually re-introduce some “trigger” events, along with good recovery support. This would not include returning to a bar where you used to drink. But it could mean going to a restaurant or party where alcohol will be served. There could be a local bar and grill that is known for its wings. Going there in early recovery is not a good idea, but with support later on might be acceptable. Maybe try getting takeout a few times first.

Alcohol is such a part of our society, total avoidance would mean a very sheltered and limited life. “Therefore, in order to lead any kind of normal life, gradual introduction is necessary.” There is an Italian restaurant, with an attached sports bar near a local N.A. meeting. After the meeting, some members go there for pizza; others don’t. This gradual re-introduction is just that—GRADUAL. And it shouldn’t be practiced when the person’s sobriety is unstable. Stress or instability in sobriety means that phase 1 avoidance should be instituted.

The third phase is extinction, meaning that the using trigger’s ability to activate a craving is eliminated or extinguished. A woman habitually sat in one particular barstool at home when she drank. In early recovery she learned to avoid sitting there, because it activated her “stinking thinking.” Through repeated times of sitting in the barstool when doing other things like drinking her morning coffee and reading a book, paying her bills, etc. she extinguished sitting in the barstool as a trigger event of her cravings to drink.

This is a process of retraining your mind or desensitizing it to what used to be stimuli (triggers) to get high. You may recognize the principles of operant and even classical conditioning incorporated within Gorski’s process of disempowering triggers.  But these principles alone aren’t always enough to bring about successful extinction of a trigger. The above comments drawn from Gorski’s article suggested this—when the sporadic nature of some triggers was mentioned. “Without a clear understanding of the psychobiological dynamics of a trigger event, the only way to learn to [manage] them is through trial and error.” Why is this?

I’d suggest that humans are psychosomatic unities of body (soma) and soul (psyche). See another article, “We Are But Thinking Reeds,” for greater discussion of this concept. Existing within the soul are not only the internal events of thoughts and feelings, but deeper desires, wants and loves. In recovery you see this expressed by the phrase “I want what I want.” The ‘psychobiological dynamics’ of a trigger event engages these desires as well as the thoughts and feelings.

Disempowering triggers can extinguish the reinforcement pattern of the thoughts and feelings to the external event, but they cannot eradicate the deep desires. One of these desires is the “loaded gun” of wanting to get high. Here is where self-control in recovery comes in—learning to not act on the thoughts and feelings that stem from it; not giving into the desire to get high. At best, this desire will go into hibernation. Practicing a program of recovery will help keep it there.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.

01/19/15

The Yin-Yang of High Risk Situations

Jin and yang mask by  sognolucido

Jin and yang mask by sognolucido

We’d discussed a plan to keep Andrea as safe as possible. Her brother had urged her to come to the family Christmas celebration and she didn’t feel she could say no. Many of her family members were drinkers, but she was going with her fiancée and neither one of them would be drinking. Most family members knew she’d just got out of rehab at the beginning of December and were supportive of her abstinence. Her brother had vowed to tell their heavily drinking uncle to keep his distance from her. She also wanted to show her family what the sober Andrea looked and acted like. Last Christmas has been a disaster.

She had talked ahead of time to her sponsor about going and agreed to call her at least once during the celebration and after she had returned home. She arranged with Chad, her boyfriend, and Matt, her brother to approach them and say she had to leave if she felt triggered by anything. Andrea and Matt rode together to the party, so they could leave whenever they needed. Her sponsor had also told her about a late night meeting she could get to as well. The party was great. She wasn’t triggered. Even Uncle Al seemed to have been more sober than usual.

A few days later, she had a phone call from a friend’s mother telling her that the woman’s niece had overdosed the night before. Andrea had known the woman, and even talked to her when they met at the grocery store, just after Andrea had got out of rehab. Although she was freaking out on the inside, she felt she had to listen to the friend’s mother and try to comfort her. Andrea still felt guilty that she had introduced the woman’s daughter to heroin. The first anniversary of the girl’s death from a car crash had come while Andrea was in treatment.

When Andrea got off the phone fifteen minutes later, she was shaking. She didn’t want to call her sponsor again; they’d talked earlier in the day and she knew her sponsor was going to be at a family dinner. She told Chad what had happened and said she was going to take a walk to clear her head—alone. Down the block, she decided to walk to the convenience store for a pack of cigarettes; she was almost out. Standing in line with her back to the front door and replaying the conversation with the friend’s mother in her head, she didn’t see a drug dealer she knew until he tapped her on the shoulder and called her name.

Andrea was in two situations that could be dangerous to her recovery. The first was one of her choosing; the second she didn’t see coming. Nevertheless, they both fit what Terence Gorski would describe as a High Risk Situation (HRS). Gorski said that a high risk situation is: 1) any experience that causes you to either move away from support for your recovery; or 2) leads to you going around people, places and things that would support your return to addictive use. He then specified this yin-yang of people, places and things and addiction further by giving a list of ten criteria:

To be more specific, a high risk situation can be described as any experience that meets one or more of the following criteria. The more criteria that are part of the experience, the higher the risk of starting addictive use.

Andrea’s first situation, going to the family Christmas party, would have met numbers 2, 3 and 4 on Gorski’s list. She was around people who would support her return to drinking (Possibly Uncle Al, maybe others who didn’t understand why she couldn’t just one drink to celebrate). She had easy access to alcohol. She was around other people who were acting out on their addiction (at least Uncle Al). But she had a plan to minimize the high risk criteria.

As Gorski noted in his article, having a plan to extract yourself from a high risk situation and then getting in contact people supportive of your abstinence can help you get away from it without using. Andrea went with her fiancée, who also wasn’t drinking. Her brother and others at the party knew she was abstinent and were supportive of her recovery. She had a plan to get to a meeting if indeed she did start to have thoughts or cravings to use. She told others of her planned emergency exit strategy. She went into a high risk situation with a plan and got out without using.

The second situation is less obviously a high risk situation because of the chance encounter Andrea had with the drug dealer. Does this mean she can never be out alone? Gorski said that in relapse prevention there are “Apparently Irrelevant Decisions that put people in high risk situation that seem to happen by chance.” In Andrea’s case, she felt she needed to try and comfort her friend’s mother even though she was freaking out inside. She should have ended the conversation or had Chad try and console the woman. She also chose not to call her sponsor—even though it made sense not to do so at the time. She went out alone and then decided to go for cigarettes—again alone—while she was still upset by her phone call.

These seeming irrelevant decisions on her part led to Andrea being alone while she was around a person who would support her drug use and even supply what she needed to get high. All the while she was still struggling to control strong feelings and emotions from her phone conversation. She also had limited options available to cope with or get out of the situation. The scenario doesn’t say what she did, but even before we speculate how she could respond, Andrea has met five of Gorski’s ten criteria. And remember, the more criteria that are part of the experience, the higher the risk of using.

Andrea are her situations are fictional, but the various pieces of each of them have really happened to people I’ve known in early recovery. Sometimes it can almost feel like an improbable scene scripted in a bad Hollywood movie. So how does Andrea keep herself prepared for the unexpected high risk situation? Simply reverse Gorski’s two yin-yang criteria—move away from people, places and things that support your return to addictive use; and put yourself around the people, places and things that support your recovery. Apply it to Andrea’s situation and see what you think she should do.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.

09/1/14

There is Nothing New Under the Sun

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Impression from a Sumerian cylinder seal from 2600 BC. Persons drinking beer are depicted in the upper row.

I have never used any mind altering drug that was not pharmaceutical grade. People who put drugs of unknown composition and purity in their bodies are either ignorant (they don’t know the real risks to the brain and mind), stupid (they know the risk and choose to ignore it), or addicted (they know the risk, want to stop, but find that they can’t). ~ Timothy Leary, in a private conversation with Terence T. Gorski.

Terence Gorski posted this quote at the end of a brief essay, “Poison as a Preferred Pleasure.” He first expressed his amazement with how many people today view alcohol and marijuana as harmless. Even more frightening to him was the willingness of people to experiment with new, largely unknown substances in the pursuit of getting high. See my essay on Playing Chemical Whack-a-Mole.

From the earliest times of culture and civilization, humans have pursued intoxication. According to Ronald Siegal, “Throughout our entire history as a species, intoxication has functioned like the basic drives of hunger, thirst and sex. . . . It is as bold and inescapable as the drug stories that dominate today’s headlines.”

The first mention of drunkenness in the Bible is when Noah became intoxicated after he planted a vineyard and ate some of the grapes. He gets naked, passes out and is seen by one of his sons, Ham. But I’m intrigued by the commentary on this story within a Hebrew midrash, Midrash Tanuma. There, the story is that Noah and Satan entered into a business arrangement to plant a vineyard. It was through this partnership, that Noah learned about the intoxicating qualities of wine. Satan’s contribution was to slaughter a lamb, a lion, a pig and a monkey and fertilize the vineyard’s soil with each in turn. What Noah learned from this was:

If a man drinks one glass, he is as meek as a lamb; if he drinks two glasses, he is boastful and feels as strong as a lion; if he drinks three or four glasses, then behaves like a monkey, he dances around, sings, talks obscenely and does not know what he is doing; and if he becomes intoxicated he resembles the pig.

The process of fermenting beverages like wine and beer runs parallel with the transition of humanity from hunter-gatherers into farmers, and eventually to cities and civilization. Beer was most likely a staple of human diets before wine was. It has even been argued that the discovery of the intoxicating effects of beer was a motivating factor for our hunting-gathering ancestors to settle down and become farmers.

2954474f708cf44b07237af4d40e46e7By the time that writing was invented, beer was no longer just an agricultural product of the rural villages. It was one of the surplus products important to the centralized economy of Sumerian city-states. The discovery of administrative cuneiform documents of the production and consumption of beer illustrates the important economic role beer played in Sumerian culture. The earliest known written documents are Sumerian wage lists and tax receipts which contain the symbol for beer, one of the most common words in the documents.

cuneiform tablet depicting beer allocation, c. 3000 b.c. British Museum Photograph: takomabibelot on Flickr

cuneiform tablet depicting beer allocation, c. 3000 b.c. British Museum Photograph: takomabibelot on Flickr

From the beginning, beer had an important social aspect. Sumerian depictions from the third millennium BCE (like that above) show two people drinking through straws from a shared vessel. The technology to filter out the grain, chaff and debris from beer had been developed, but the continued use of straws suggested this was a ritual that persisted even after straws were no longer needed. Perhaps sharing a drink was a symbol of hospitality and friendship. “It signals that the person offering the drink can be trusted, by demonstrating that it is not poisoned or otherwise unsuitable for consumption.”

Beer had a religious role in Sumerian culture as well. The Hymn to Nakasi was simultaneously a song of worship to the goddess of beer and a recipe for brewing beer! See section 6.1 of the article on Sumerian Beer for the text of the hymn. Nevertheless, Sumerian beer was likely consumed in taverns, similar to medieval times. At the end of the hymn, the goddess Nakasi pours out beer for the drinkers, giving her the role of both brewer and tavern-keeper.  Women were typically the ones who brewed and sold beer in ancient Mesopotamia.

The Egyptians also excelled in the arts of fermenting wine and brewing beer. Not only were such intoxicants for the living, they were said to be used by the dead in the afterlife. Menquet, the Egyptian goddess of beer, was pictured as a woman holding two jars of beer. Hathor, represented as a sacred bull, was the god of wine. He was duly honored on a monthly “Day of Intoxication.”

The Preacher in Ecclesiastes can help put the latest intoxicant fad with synthetic drugs or new psychoactive substances into perspective: There is nothing new under the sun. From the time human beings first settled down into villages, they have looked for new and better ways of getting high.

What has been is what will be, and what has been done is what will be done, and there is nothing new under the sun. Is there a thing of which it is said, “See, this is new”? It has been already in the ages before us. There is no remembrance of former things, nor will there be any remembrance of later things yet to be among those who come after. (Ecclesiastes 1:9-11)

Do you agree with Timothy Leary that people who put drugs of unknown composition and purity in their bodies are either ignorant or stupid?

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of blog posts based upon the material available on his blog and website.

 

 

 

 

 

08/11/14

Déjà Vu All Over Again

Leo (not his real name) walked into our outpatient clinic with a daypack over his right shoulder smelling strongly of booze. He would later show us the half-empty bottle of vodka he carried inside of it. Three of the treatment staff did an impromptu “intervention” and at one point he almost gave us the bottle. Sadly the vodka was more alluring to him at the time. He kept the bottle.

We knew and liked Leo. He had been in our partial treatment program at least 2 or 3 times before. He demonstrated personal change; helped others with their own drug and alcohol use problems; and usually completed the treatment program. But he repeatedly lapsed or relapsed into active drinking.

He wasn’t angry or belligerent. He didn’t even get upset when we told him if he walked out of the office we would call the local police. He just quietly got up and left—with his daypack. I followed him outside and watched him walk away. The last time I saw him that day he was fifty yards away; slinging his daypack off of his back as he disappeared behind some trees.

Sarah (not her real name) had completed her third or fourth outpatient treatment few months after she turned twenty. This time she had a very good sponsor; had several other women with solid recovery in her sober support system; and seemed to really be trying to remain abstinent. Then we heard that she had announced to everyone that she intended to celebrate her 21st birthday with a pub-crawl. Several people tried to talk her out of this crazy idea, but she wasn’t budging.

I got permission to hold a birthday party for her at the aftercare group I oversee. And then I invited Sarah and anyone in her sober support system that wanted to come. We had a quarter-sized sheet cake and ice cream. Sarah didn’t come, but I saved her a piece of cake and put it in my freezer. About a month later on her birthday, she went on a pub-crawl with her friend. The friend ended up in the hospital with alcohol poisoning. Sarah kept drinking and using drugs for another six or seven months.

When she came back to the Aftercare group, I told her I had a piece of birthday cake for her in my freezer.  When she achieved one year of abstinence, I’d give her the birthday cake. She returned after her one-year anniversary and I gave her the piece of cake. I haven’t heard from her for a few years, but the last news I had was that she was still sober.

Relapse into active drug or alcohol use is, sadly, a common occurrence in recovery. But it doesn’t always have to be. Like the new Tom Cruise science fiction movie, “Edge of Tomorrow,” persistence and repeated battle against addiction can be an opportunity to eventually overcoming this personalized alien invader. But if it’s addiction and not the Mimics that you battle, I suggest you trust in Terence Gorski and not Tom Cruise for your deliverance.

Among the many tools developed by Gorski for this battle is the AWARE (Advance WArning of RElapse) Questionnaire.  It was designed and refined as a measure of the warning signs of relapse. It is simple to use and interpret: the higher the score, the greater the number of relapse warning signs being reported. It was developed through research funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). So it is in the public domain and may be used without specific permission; so long as the proper recognition is given as to its source.  You can read Gorski’s original blog post on the AWARE Questionnaire. And you can download a printer-friendly version of it that I’ve put together here.

Does the frequency of relapse among alcoholics and addicts suggest there is a flaw in abstinence-based treatment and self-help groups?

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of blog posts based upon the material available on his blog and website.