Tag: Relapse/Recovery Grid

06/6/17

Preventing the Relapse Process, Part 2

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Recovery can be likened to walking up a down escalator. Imagine an escalator that stretches so far up that it disappears in the distance. As every child knows the trick to walking up one is to climb faster than the escalator is pulling you back. You could climb so far up this imaginary escalator, that you would no longer see the bottom. But the moment your climbing effort is less than the downward pull of the escalator, you begin moving back towards that bottom. That’s what relapse is like.

You might even be objectively climbing up the escalator, but if it isn’t enough to counter the downward pull, you have only delayed the inevitable. You have to be climbing as least as fast as the escalator is pulling you back to not lose ground. And that is what relapse prevention is like.

Relapse is a process, not an event. The last thing that happens in a relapse process is resuming alcohol or drug use. Depending on the effort you made to progress up the escalator of recovery, your relapse process could take a long time to play out. I’ve known people who identified patterns of relapse that stretched over years of their abstinent lives before they resumed active drinking or drugging. Perversely, this can be a message of hope and not hopelessness. If your relapse process takes months or years to lead you back to active drinking or drug use, then you have months or even years to recognize the problem and prevent it from getting any worse.

In the first part of this article we looked at coping with problems or stuck points in recovery and the high risk factors and trigger events that increase the likelihood of relapse if they are handled incorrectly.  This discussion on relapse applies the thinking of Terence Gorski on relapse and relapse prevention, particularly his use of the Relapse/Recovery Grid in Passages Through Recovery and the booklet, The Relapse/Recovery Grid.  There are also several articles using this material available on his blog, Terry Gorski’s Blog, including: “Understanding Relapse and Relapse Prevention.”

“The general direction towards relapse is from denial and evasion to high-risk lifestyle factors.” We left off a discussion of the relapse process in Part 1 with a description of high-risk situations and trigger events. High-risk factors make you vulnerable to trigger events, which can be “anything that causes sudden stress, pain, or discomfort.” They can be internal or external triggers. The interaction of high-risk situations and trigger events determines how the Relapse Process advances.

When there are relatively few high-risk factors in a person’s life, it will take a greater stressor to trigger the internal dysfunction of relapse. Conversely, with more high-risk factors, even a minor event can trigger internal dysfunction. “As internal dysfunction increases, the ability to manage reality gets worse, and more problems develop.” This internal dysfunction in early recovery is post acute withdrawal (PAW). See “Recognize Your PAWS” and “Manage Your PAWS.” Or you can read Gorski’s Comprehensive Guide to PAW here.

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. . . . Eventually the ability to sleep restfully is disrupted. This heightens stress and fatigue to the point where people become accident-prone.

Thinking problems can range from difficulty concentrating or thinking logically, to racing, repetitive thoughts. The person isn’t always clear about how things affect or relate to each other. “They have difficulty deciding what to do next to manage their lives and recovery.”

Feelings and emotions can range from being very sensitive to being numb. Strange or “crazy feelings” can occur for no apparent reason, leading the person to think they are going crazy. “These problems in managing feelings can cause recovering people to experience mood swings, depression, anxiety, and fear. Sometimes in this situation a mood disorder is diagnosed and treated with medication. Ironically, this could exacerbate the internal dysfunction of relapse. The person often doesn’t trust their emotions and seeks to ignore, stuff or forget them.

Memory problems interfere with learning new skills and retaining new information. Remembering what you just read can be difficult. “The new things they learn dissolve or evaporate from their mind within minutes.” Taking classes or learning a new job skill can be tough when this is happening.

Sleep-related problems can crop up. This could mean trouble falling asleep, trouble staying asleep, and even unusual or disturbing dreams. Restful sleep may be difficult to come by, leading to exhaustion or tiredness during the day.

Problems managing stress begin with a failure to recognize the minor signs of daily stress. So when stressors become evident, there is a tendency to overreact to them. “Stress sensitivity causes them to amplify, magnify, and intensify whatever feeling they are experiencing.” At times, they get so tense and the strain is so severe, they can’t function normally.

This internal dysfunction can lead to feelings of shame and guilt; feeling you are doing something wrong in recovery or not working a good program. This can lead to not talking honestly about what you are experiencing. These warning signs of relapse get stronger the longer they remain hidden. “Secrets keep you sick.” If you try and fail to manager them alone, you may begin to feel hopeless.

External Dysfunction

Problems in living emerge from a failure to manage the internal dysfunction issues of a relapse process. “Now problems arise at work, at home, with friends, and with fellow members of the program.” If there is a person (like a sponsor) or a situation (like a meeting) that might call on you to take an honest look at yourself, you begin to avoid them and isolate. If asked how you’re doing, you get defensive or lie. Impulsive actions, doing things without thinking them through can happen.

Confusion, overreaction and crisis building occur. “Here, people may begin to have problems cause by denying their feelings, isolating themselves, and neglecting their recovery.” You get upset with yourself and others. You can be irritable and overreact to little things. Relationships become strained; conflicts arise. Stress and anxiety increases. At this stage, denial locates the problems in others or outside situations.

Loss of Control

Active addiction is often described as a loss of control. I find it helpful to distinguish between two kinds of loss of control: the loss of control over thinking, feeling or behavior; and the loss of control over drug or alcohol intake. Here the first sense of loss of control is activated. I describe this stage of the relapse process as feeling like a deer caught in the headlights. There is poor judgment; an inability to take action; an inability to resist destructive impulses.

Recovering people lose their ability to control their thinking and behavior. Judgment is impaired. They often know what they need to do but can’t do it. They begin to have cravings and self-destructive impulses and find the more and more difficult to resist. They consciously recognize the loss of control, but believe they can’t do anything about it.

Far too often, this is the first awareness the person has that they have slipped into “relapse mode.” They see how severe their problems have become; how unmanageable life has become and how little power they have to solve their problems. “By this time, they have become so isolated that it seems there is no one to turn to for help.” Feelings of powerlessness to resolve problems leads to believing you are useless and incompetent.

Feeling trapped by pain and inability to manage life, they feel their options are reduced to going insane, committing suicide or using drugs or alcohol. There is no sense that anyone or anything can help. Twelve Step meeting attendance stops, if it hasn’t already. Tension can lead to terminating a relationship with a sponsor of counselor that used to be helpful.

People can only live with debilitating stress for so long before they collapse. Some people collapse physically and develop stress-related illnesses such as ulcers, gastritis, back pain, hear disease, or cancer. Others collapse emotionally … [or] become suicidal.

Lapse/Relapse

“When faced with the limited alternatives of physical or emotional collapse, suicide or chemical use, using can seem like the sanest choice.” Assumed here is the person does know, or did know from experience when they were using in the past, that it’s likely they would again lose control over their use. Either they are so desperate that they convince themselves they will only use for a short while in a controlled way, or they impulsively act when an opportunity to use presents itself. This initial use will often produce intense feelings of guilt and shame for the individual.

Sometimes active using is a lapse—a short time period, perhaps even one night or a few drinks. Other times the active use spirals out of control and can go for months or years. Returning to a loss of control over use can be slow or rapid. Often the person quickly returns to using as much as they did before.

The goal of relapse prevention is to interrupt the above-described process as quickly as possible. The further the relapse process progresses, the more difficult it is to stop. Identifying and resolving stuck points (see part 1), avoiding as many high-risk factors as possible, and neutralizing trigger events are the best interventions. Next would be catching and addressing internal dysfunction, then external dysfunction and finally loss of control before the relapse into active chemical use. Remember that when you successfully intervene in a relapse process at the beginning, you need never risk actually picking up.

This is part 2 of my article, “Preventing the Relapse Process.” Part 1 describes stuck points, high-risk factors and trigger events connected to the relapse process and it can be found here.

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 websites.

05/26/17

Preventing the Relapse Process, Part 1

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Relapse is a terrifying experience for an addict or alcoholic to go through. And what seems to be most terrifying, is not being able to see it coming. Hindsight will recognize a few obvious mistakes, but often there is a haunting question: “What am I missing?” Learning to understand relapse and how to prevent it are essential pieces to the recovery puzzle. Relapse doesn’t have to be part of recovery, but recognizing the process when it occurs is essential.

Gerald finally agreed to admit himself to an addictions treatment center. He had relapsed into active drug and alcohol use two years ago after having eight years of abstinence. At the time of his relapse, he was the manager of a sober living residence that housed 10 to 12 men who needed a supportive living environment in early recovery. He didn’t recognize any one thing or event that triggered his relapse. But the guilt after picking up was more intense then he imagined was possible. He was the guy at meetings who always said he put his recovery first.

He acknowledged he had been going through the motions for a while. But that had happened to many others he knew who didn’t pick up. There was the usual recognition of slacking off on going to meetings and growing more impatient with others asking him if he was “all right.” But he honestly couldn’t pick out any one thing or a series of events that led to his relapse.

He had wracked his brains trying to think of what he should have done differently, but he couldn’t see where he went wrong. Privately he was terrified. What if it happened again and he didn’t see it coming that time either? He was afraid he wouldn’t make it back again.

There is no better place to start helping Gerald than with the resources developed by Terence Gorski for understanding and preventing relapse. His Relapse/Recovery Grid has been one of my most regularly used tools when I work with individuals to address their alcohol or drug problems. You will find it in at least two places. The first is within his book, Passages Through Recovery and the second is in his booklet, The Relapse/Recovery Grid. Another helpful resource is Terry Gorski’s Blog, where Terry has made a wealth of his material available. I haven’t seen a reproduction of the 8 ½ by 11 inch Relapse/Recovery Grid available on his blog, but in several articles like “Understanding Relapse and Relapse Prevention,” you will get a good synopsis of the Relapse Process summarized on the bottom half of the Relapse/Recovery Grid.

Gorski said relapse is like knocking over a line of dominoes. It is a process of one unresolved problem leading to another, and then another and another—until you have a major crisis, where using alcohol or drugs to deal with the pain seems like a reasonable choice. “The answer to avoiding relapse is to learn how not to tip over the first domino, and take care of the little problems in life.” If the dominoes have already begun to fall by the time you realize what’s going on, then you want to stop the chain reaction quickly, “before the dominoes start getting so big and heavy that they become unmanageable.”

One way the domino analogy is not always accurate is in the amount of time involved in a relapse process. Someone with stable recovery can take a long time to move through the stages of a relapse process before they ultimately use drugs or alcohol. By stable recovery, I mean someone who is in what Gorski calls the Maintenance Stage of the recovery process. This is where the person is maintaining a recovery program, coping effectively with day-to-day issues in life, continuing to grow personally and spiritually, and coping effectively with the crises and transitions that occur in life. I’ve known an individual who said her relapse process started four years before she actually used drugs again.

Perhaps a bit counter intuitively, this longer time for relapse to result in active drinking or drug use can be helpful IF the person recognizes the problem (or stuck point in Gorski’s discussion of the relapse process) and copes effectively with it. This necessitates the use of RADAR to address the stuck point: Recognizing there is a problem; Accepting that it’s normal to have problems and get stuck in recovery; Detaching or backing off to gain perspective on an unsolved problem; Accepting help from others—asking them for help with your problem; and Responding with positive action will help you get over the stuck point and avoid a further slide into the relapse process.

Failing to address a stuck point leads to ESCAPE: Evading or denying the problem or stuck point; failing to cope with the Stress that comes with evading the problem; turning to Compulsive behaviors to cope with the pain and stress; Avoiding others, especially those who see and tell you about your ineffective strategies for dealing with the problem; developing new Problems from the process of stress, compulsive behavior and isolation; and ultimately Evasion and denial of the new problems—see how it’s been working so well for you so far.

Instead of recognizing you are stuck and need help, you try to tell yourself everything is okay; you are coping effectively. But there is a buildup of pain and stress that can result in using other compulsive behaviors to cope.

To cope with the pain and stress, we begin to use other compulsive behaviors. We may begin overworking, over-eating, dieting, or over-exercising. We can get involved in addictive relationships and distract ourselves with sex and romance.  These behaviors make us feel good in the short run by distracting us from our problems.  But they do nothing to solve the problem.  We feel good now, but we hurt later.  This is a hallmark of all addictive behaviors.

Then something happens. Usually it’s something you would handle without getting upset. But this time you’ve had it; you’ve hit your limit and something snaps inside. Gorski said one person said it was like a trigger going off in your gut and you go out of control. But this is not actively drinking or using … yet. “When the trigger goes off, our stress increases, and our emotions take control of our minds. . . . When emotion gets control of the intellect we abandon everything we know, and start trying to feel good at all costs.”  There was just one too many stressors that weren’t addressed, so a trigger event initiates the internal dysfunction of the Relapse Process.

The Relapse/Recovery Grid lists several high-risk lifestyle factors that increase the likelihood of something triggering the Relapse Process. “These high-risk factors don’t cause relapse; they simply increase the likelihood that it will occur” by making you vulnerable to trigger events. The high-risk factors include personality stressors (perfectionism; or controlling); high-risk lifestyles (trying to do too much or doing too little; or doing the wrong things); social conflict and change; poor health maintenance (poor nutrition, a lack of exercise, relaxation or socializing) or other illness; an inadequate recovery program. “The ‘wrong things’ could be occupations, activities, and people that don’t fit with natural preferences and talents.” Gorski said these high-risk factors were identified from research into the lifestyles of people who had relapsed.

The trigger events listed in the Relapse/Recovery Grid include: high stress thoughts, painful emotions, painful memories, stressful situations and stressful interactions with others. Gorski said that just about anything could become a trigger event, but these five things trigger internal dysfunction more than others.

Some recovering people put themselves under increasing amounts of stress, and they keep adapting to it as they go along. As their tolerance goes up, they block their awareness of stress. Suddenly they hit their limit. They experience one stressor too many, and become dysfunctional.

Irrational thinking is the most common trigger. All-or-nothing thinking, black-and-white thinking fits here. When something goes wrong, you think Nothing ever goes right. If there is a risk of failure in doing something, you quit before it happens. This kind of thinking is irrational.

Emotional pain can point to something wrong with how you are thinking or acting. It signals “a need to examine what is wrong.” If you dismiss painful emotions for too long, they often come back with a vengeance.

People will often experience stressful or traumatic events in an active addiction that cause them extreme emotional or physical pain.  Being reminded of these events can lead to disorientation, confusion, anxiety or other symptoms for no apparent reason. This will then increase stress and trigger internal dysfunction.

“Any situation that a person is not prepared to cope with may be stressful.”  Recognize this reality and seek to avoid them, if at all possible, by being prepared. The level of stress is inversely related to your preparation: it goes down as your preparation goes up. In situations where you can’t be prepared, learn some stress reduction skills, such as relaxation breathing. See “Using Stress Management in Relapse Prevention Therapy (RPT)” and  “Stress Self-Monitoring and Relapse” for more on this.

Stressful interactions with others are common for recovering addicts and alcoholics. They often have high stress people in their lives, meaning people who cause them stress. Often these high stress interactions occur with family members or people the addict or alcoholic is close to. Their stressful behavior, ironically, is often caused by their fear of a relapse with the addict.

This is the first part of my article, “Preventing the Relapse Process.” Part two will describe the four phases of the Relapse Process and it can be found here.

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 websites.