Tag Archives: mistaken beliefs about relapse

10/31/17

Mistaken Beliefs About Addiction Relapse

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The coroner’s report on Carrie Fisher’s death listed sleep apnea as the primary cause of death with drug intake as a contributing factor. In addition to the medications prescribed for her bipolar disorder (Abilify, Lamictal and Prozac), toxicology results found cocaine, methadone, heroin, oxycodone, and MDMA (ecstasy) in her system at the time of her death. Fisher’s family objected to a full autopsy, so the coronor’s conclusions were based on the toxicology results and an external examination of her body. “Based on the available toxicological information, we cannot establish the significance of the multiple substances that were detected in Ms. Fisher’s blood and tissue, with regard to the cause of death.”

The above information was from an article in Variety, but several media outlets were citing the coroner’s report and the same information. People said the coroner’s report indicated Ms. Fisher used cocaine sometime in the 72 hours prior to her death. During her 10-hour flight, she had multiple apneic episodes, which her personal assistant said was normal for her. Towards the end of the flight, she could not be roused. The report also noted she suffered from atherosclerotic heart disease, but then said: “The manner of death has been ruled undetermined.”

Although the official coroner’s report listed the manner of death as undetermined, it seems reasonable to assume from the toxicological information that Ms. Fisher had relapsed into active substance use. Billie Lourd, her daughter, said in a statement to People: “My mom battled drug addiction and mental illness her entire life. She ultimately died of it.” The cocktail of substances in Carrie Fisher’s system at the time of death, along with her history of heart disease, coupled with the increased risk of sudden cardiac death due to the medications used to treat her bipolar disorder lends credibility to Ms. Lourd’s statement.

The use of psychiatric medication to treat her bipolar disorder may have been a contributing factor to Ms. Fisher’s heart failure. See the article, “Blind Spots with Antipsychotics” Part 1 and Part 2 for more on the health problems with antipsychotics. But the range of substances she used just before her death may also have been enough to precipitate a sudden cardiac death, particularly since she already suffered from heart disease. Struggling with a concurrent bipolar disorder and a substance use disorder is a double whammy to anyone in recovery. Instability with either issue is a serious risk factor for relapse. I knew of someone with a bipolar diagnosis and cocaine dependence. They bounced back-and-forth between active cocaine use and inpatient psychiatric treatment for depression ten times within a single year.

Ms. Lourd said her mother would want her death to encourage people to be open about their struggles, and to seek help for them. Historically, Carrie Fisher talked openly about her proneness to relapse. She told People in 1987: “I couldn’t stop, or stay stopped. It was never my fantasy to have a drug problem.” She would stop for a couple of months and then celebrate her abstinence by using again. “I got into trouble each time. I hated myself. I just beat myself up. It was very painful.” With that in mind, let’s assume the immediate cause for her untimely death was due to an apparent relapse into active drug use, and then discuss some mistaken beliefs about addiction relapse.

Terrance Gorski is a leading expert on addiction relapse prevention. He’s written several books on the subject, many of which are available through Herald House Independence Press at relapse.org. He also has a blog, Terry Gorski’s Blog, where he has made a significant amount of his material available for free. Here we’ll concentrate on his article, “Relapse Does not Mean Failure?”

Gorski said there were three mistaken beliefs that often interfered with helping relapse prone individuals. They are: (1) Relapse is self-inflicted; (2) Relapse is an indication the person is a failure who doesn’t want to recover; and (3) Once relapse occurs the patient will never recover.

In most cases, relapse is not self-inflicted. There isn’t a fully conscious, willful decision to throw over abstinence and return to active drinking or drug use. Relapse-prone individuals “experience a gradual progression of symptoms in sobriety that create so much pain that they become unable to function in sobriety. They turn to addictive use to self-medicate the pain.” They can learn to stay sober by recognizing these symptoms as early relapse warning signs. Next is identifying the self-defeating thoughts, feelings and actions used to cope with the symptoms and then learn more effective coping mechanisms, more healthy ways of responding to them.

Unfortunately, most relapse-prone patients never receive relapse prevention therapy, either because treatment centers don’t provide it or their insurance or managed care provider won’t pay for it.

Relapse is not automatically a sign that treatment has failed or the person really doesn’t want to recover. It is more likely that the root-cause of the person’s problems wasn’t addressed by the “standard package of treatment offered.” If this is the case, the risk of relapse increases dramatically. Learning to recognize relapse warning signs and how to cope with them would minimize this risk.

Gorski said that between one half and two-thirds of all individuals treated for alcohol and drug use problems will relapse. At least one half of those who relapse will establish long-term recovery within five to seven years of their first treatment experience. Believing that relapse means both the person and the treatment failed ignores the reality that for many, recovery involves a series of relapse episodes. “Each relapse, if properly dealt with in a subsequent treatment, can become the a learning experience which makes the patient less likely to relapse in the future.”

Chemically dependent people can be grouped into three types based upon their recovery and relapse histories. The first type is recovery prone and maintains total abstinence from their first serious attempt at change. Another type is relapse prone, with a series of short-term, low consequence relapse episodes before finding long-term abstinence. The third type is chronically relapse prone, who can’t seem to find long-term sobriety regardless of what they do.

Recovery prone individuals tend to be dependent on a single drug. They also have higher levels of social and economic stability. They may have steady employment, friendships and stable living situations. And they don’t have coexisting mental health issues, as Carrie Fisher did, or physical health issues, like chronic pain problems. These “garden variety addicts” have chemical addictions with few additional serious personal or social problems.

The second type of transitionally relapse-prone individuals, seem to have more severe addictions that are complicated by other problems. However, they learn from each relapse episode and take steps to modify their recovery programs to avoid future relapses. For example, they may downplay the risks of going around good friends who still drink or use drugs until they find themselves actively drinking or drugging again. Afterwards, they set and keep boundaries with those friends that better support their recovery.

The third type— chronically relapse-prone individuals—not only have the primary addiction for which they are being treated, but also a combination of the following coexisting issues. They may have multiple drug addictions, especially with opiates and methamphetamines. They can have an undiagnosed physical condition, a personality disorder or other mental health problem. There could be issues with severe post acute withdrawal (PAW), which becomes even more severe when the person is under high levels of stress.

Many relapse-prone patients fail to recover because these coexisting [issues] are not properly diagnosed and treated and they interfere with the primary treatment being given.

The third mistaken belief sees recovery as an all-or-nothing process—you either have it or you don’t. And if you relapse, you just don’t want recovery bad enough. Actually, recovery is a learned skill, acquired mostly by trial and error.  Rarely does someone with long-term recovery get there without one or more short series of relapse episodes. “They learned from these experiences and figured out how to put together a meaningful and comfortable long-term recovery.”

So when you think about Carrie Fisher’s toxicology report, don’t assume she threw away her sobriety like it was an old, worn out Alderaan gown. Her relapse was likely the result of a gradual progression of symptoms occurring in her life. In time, they created so much pain in sobriety that she wasn’t able to function. So she tried to self-medicate. She also wasn’t a failure who didn’t want to recover. The openness in her life about her struggles with addiction and mental health belie such an assessment.

Like thousands of others each year, she died with multiple psychoactive substances in her system. But that doesn’t mean she would have never made it back to abstinence. Remember, she was Princess Leia; and Leia Organa never gave in to the tyranny of the Empire. Carrie Fisher would never have given up fighting against her addiction and mental health demons.

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.

07/25/17

Keep on Knocking

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The first sentence for the Step Eleven essay in Twelve Steps and Twelve Traditions succinctly says: “Prayer and meditation are our principle means of conscious contact with God.” Bill W. went on to say there were some who recoiled from meditation and prayer “as obstinately as the scientist who refused to perform a certain experiment lest it prove his pet theory wrong.” Yet for those who made regular use of prayer come to see it as necessary for their survival as air, food or sunshine: “We all need the light of God’s reality, the nourishment of His strength, and the atmosphere of His grace.”

“Ask, and it will be given to you; seek, and you will find; knock, and it will be opened to you. For everyone who asks receives, and the one who seeks finds, and to the one who knocks it will be opened. Or which one of you, if his son asks him for bread, will give him a stone? Or if he asks for a fish, will give him a serpent? If you then, who are evil, know how to give good gifts to your children, how much more will your Father who is in heaven give good things to those who ask him! (Matthew 7:7-11)

In verse 7, there are a series of commands: ask, seek and knock. All three are in the present tense, which suggests we are to persist when we come to God in prayer. We should petition God “with an expectant attitude,” according to Craig Blomberg. In verse eight, we have a repetition of what to expect when we pray: all who ask receive; everyone who seeks something will find it; when someone knocks on a closed door, it will be opened. But it would be a mistake to use this as a kind of incantation with which we can petition and receive from God whatever we desire.

Bill W. astutely noted that when we ask for specific solutions to specific problems, and for the ability to help other people as we think they need to be helped, “We are asking God to do it our way.” We should consider each request carefully to see its real merit. His advice when making specific requests was to add a qualification: “ . . . if it be Thy will.”

We discover that we do receive guidance for our lives to just about the extent that we stop making demands upon God to give it to us on order and on our terms.

Not too long before this passage in Matthew was Jesus’ counsel to not pray like the hypocrites or use empty phrases (Matthew 6:5-15). Instead, we should pray humbly to our Father in Heaven, asking for His will to be done; for our daily bread (needs); for our debts to be forgiven; and to keep us from temptation. This passage, of course, was on the Lord’s Prayer. So when we self consciously acknowledge God as our Father in heaven, and seek for his will to be done on earth as it is in heaven, we can trust that He will provide for our needs. So we can confidently, ask, seek and knock. And when we ask according to His will we will receive; we will find what we seek; we will open what was closed to us when we knock.

The rhetorical questions in Matthew 6:9-10 imply a negative answer: of course a human father would not be so obtuse when responding to the requests of his son. He would not give a stone when asked for bread or a serpent when asked for a fish. Bread and fish would have been common foods for the people listening to Jesus give the Sermon on the Mount, again pointing back to relying upon God for our daily needs.

There is also a possible allusion to a sense of trickery—bread can be shaped to look like a stone; snakes can be mistaken for a certain eel-like fish catfish in the Sea of Galilee.  If a human father can be trusted to give good things to his son, can’t we place even greater trust in God the Father? Jesus is reasoning from the lesser to the greater here. If such trickery or obtuseness would be unthinkable in a human father, “how much more” can our heavenly Father be trusted?

So the lesson of the passage is that we can trust God to answer our prayers. When we ask according to His will, we will receive. When we seek our daily needs, we will find them. And when a door appears closed to what we ask or seek, if we knock it will be opened for us. Here the call is for hope and perseverance. We are to continue asking, seeking and knocking until the seemingly closed door to us is opened, because we can trust God to meet our needs.

This call for persistence in prayer also applies to those who have tried to give up drugs and alcohol but failed repeatedly. There is a sense of dread that overcomes the person who has made repeated attempts to stay abstinent and failed. They begin to think there is no hope for them; that they are “constitutionally incapable of recovery.” This is a mistaken belief about recovery and relapse. In his booklet Mistaken Beliefs About Relapse, Terence Gorski said: “A mistaken belief is something that you believe is true and act as if it were true when, in fact, it is false.”

Continue trying to establish and maintain abstinence. Ask for guidance; seek help; keep on knocking (persist in asking and seeking) until you obtain it.  Because you won’t be tricked or be given something that won’t meet you needs (a stone or snake).

This is part of a series of reflections dedicated to the memory of Audrey Conn, whose questions reminded me of my intention to look at the various ways the Sermon on the Mount applies to Alcoholics Anonymous and recovery. If you’re interested in more, look under the category link “Sermon on the Mount.”

07/7/14

Never Give Up Hope

Adam’s lead was one of those powerful tales of riches-to-rags-to-riches of drinking and drug use leading to a “low bottom” and then recovery. His bottom included being homeless; losing his job; jail; the whole works. And then he got sober. He always concluded by saying: “And I know that if I ever were to pick up again, I’m never coming back.” He meant what he said. His audience believed him. And when he did pick up, he never came back.

When I was an intern at an outpatient drug and alcohol clinic, I heard the tale of Adam’s relapse. That wasn’t his real name; I don’t think I ever knew it. But Adam’s story was my first lesson in mistaken beliefs about relapse: His mistaken belief about relapse created a self-fulfilling prophecy.

In his booklet Mistaken Beliefs About Relapse, Terence Gorski said: “A mistaken belief is something that you believe to be true and act as if it were true when, in fact, it is false.” Within it, he listed seventeen separate mistaken beliefs. Adam seems to have believed numbers 16 and 17.

Number 16: “Once you begin using it is impossible for you to interrupt your relapse before you have ‘hit bottom’ again.” Many addicts program themselves for a destructive relapse. They believe that it is better to be dead than drunk or high. This seems to be what Adam had buried in the concluding statement to his lead. Once he started, he believed there was no way he could stop. His first bottom was so low, that next was death.

It is true that once you again begin to use addictively, you can never be sure of what is going to happen. But you can have periodic moments of sanity; times where you “regain control of your thinking, your emotions, your memory and your behavior and judgment. . . . It is your responsibility to yourself and those whom you love to get help to interrupt the relapse during these moments of sanity.”

Number 17: “Successful recovery from addiction requires continuous abstinence from the time of the initial commitment to sobriety.” It is a fact that most addicts and alcoholics are not able to maintain permanent abstinence the first time they try. But this is NOT MEANT to be permission to periodically drink or use. There is a difference between a lapse—the initial return to addictive use, and a relapse—the destructive return to loss of control, addictive use.

There are two choices. The person can get help from others to return to abstinence (call your sponsor or others people in your support system; get back into treatment). Then they need to learn from the experience what went wrong; and what they need to do to stay sober in the future. Or they can convince themselves that staying sober is hopeless and continue to use destructively. “If they believe they are hopeless or that they have failed totally because they have lapsed, they will give up and not continue in their efforts to recover.” Sometimes they are lucky enough to have the right set of circumstances re-engage them in treatment or other help. Sometimes they die in their addiction like Adam.

In his blog post on Mistaken Beliefs About Relapse, Gorski discussed what he called the three most common mistaken beliefs about relapse: 1) that it is self-inflicted; 2) that it is an indication of treatment failure; and 3) once relapse occurs the person will never recover. These mistaken beliefs are differently worded than those in his booklet, Mistaken Beliefs About Relapse, but still worth reading and thinking about in their own right.  Adam seems to have fallen prey to the third one.

There are two additional mistaken beliefs I hear a lot: First, that relapse is a part of recovery. Relapse is often a part of someone’s recovery journey, but it doesn’t have to be. Second, some people are “constitutionally incapable” of recovery. Here, Gorski said it best: “The consequence of believing you cannot get well is despair. Without hope there is no motivation to try again and you are condemned to a life of despair.” Never say never. And never give up hope.

What other mistaken beliefs about relapse or recovery have you encountered? 

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.