17. Relapse & Relapse Prevention - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Mine, Yours, and Ours, Addiction and Compulsivity in Couples and Couple Therapy
Chapter 17: RELAPSE & RELAPSE PREVENTION


Relapse, or a return to the problematic use, behavior, or relationship is often a normal part of an addict's recovery process.  "The rates of alcohol relapse varied in different studies from 35%, up to as high as 90%" (Walter et al., 2006, page 100).  Return to alcohol, drug use, or compulsive problematic behaviors is more likely than not.  Relapse may be a defining distinction between problematic use and dependence.  Once an individual experiences significant problems from use or behavior, he or she would be otherwise motivated to stop or curtail it.  On the other hand, continued or return to use or behavior- that is, relapse is fundamental to addiction.  Treating addiction essentially includes dealing with relapse.  "A major challenge of treating addiction is facilitating a growth perspective and response to relapse- one that neither sidesteps nor inflates the significance of relapse.  As treatment progresses, partners gradually venture to hope for recovery.  Relapse can be potentially devastating for both partners, even if the therapist has attempted to normalize relapse as part of the broader trend for recovery.  The primary therapeutic goals following a relapse are to (1) assess each partner's views of the relapse and the attendant emotions, including guilt and/or shame; (2) validate each partner's experience while also modeling proper perspective-taking of the relapse; and (3) facilitate a change and growth outlook of the experience; thereby increasing self- and other- understanding, empathy, and nascent softening (Seedall and Butler, 2008, page 88).

Normally used in reference to alcoholism and substance addiction, relapse prevention principles can also be applied to behaviors in the couple's relationship.  In the couple's relationship, the partner often sees a relapse- a return to problematic use or behavior as a betrayal.  "If he/she really loved me… were committed to the relationship… cared about the children, he or she would not have done it again."  "It" can be as severe as having another affair to something as simple or benign as forgetting to call or pick up a package… again.  What is seemingly simple may be highly sensationalized from having been infused with intense symbolism for a variety of reasons.  The individual by him or herself or in a couple or group often has great difficulty in quickly and efficiently eliminating problematic behavior.  Such behavior may be characterized as bad habits to compulsions to addictive behaviors such as alcoholism, gambling, and so forth.  The therapist needs to help the partners step aside from the romantic premise that love will allow or empower someone to transcend his or her humanity- including specifically, his or her addiction.  Acknowledging the depth of the habit, compulsion, addiction, or dependence is important for the partner and the transgressor (addict or betrayer) to begin work on recovery.

As the depth of the issue is acknowledged, then moving forward to have an actual therapeutic and life plan to deal with the probability of relapse becomes possible.  Behaviors that can just be stopped once they are identified are not the reasons couples break down or present for therapy.  "Just stop it!" works for simple behaviors that do not have significant compulsive and/or highly charged symbolic foundations.  Problematic behaviors that threaten relationships almost always have those underlying issues.  And, as a result are hard to eliminate.  The individual becomes prone to relapse or to repeat the behaviors despite the harm it causes to the relationship.  Many of the principles of relapse prevention for addictive behaviors are just as applicable to other problematic behaviors.  Relapse prevention work is often needed in conjunction with other couples work for successful growth and change in the relationship.  Relapse is not an incident that occurs merely at a moment of weakness, or of opportunity.  Relapse usually occurs at the end of a series of circumstances, choices, and action and the lack of action.  There is invariably a pattern of actions and choices that led up to the relapse.

Mitchell who had a long history of alcohol and drug dependence had been sober for six months.  He had successfully nursed his pain medication to last through each month.  Then he relapsed late Saturday night.  A month earlier, he had been passed over for a promotion at work.  It had been very disappointing and somewhat depressing.  He did not discuss his disappointment and subsequent depression with anyone, including his wife Kat.  Instead, he internalized it, attempting to suppress his feelings as his alcoholic father had shown him and had expected of him.  He stopped exercising which had been helpful for him to deal with stress.  He started hanging out with his buddies after work at a bar… but having mineral water initially instead of beer.  Mitchell had arguments with Kat about it when she found out that he was doing this risky behavior.  She had seen this pattern before.  He denied that it was a pattern.  He began resenting Kat's "controlling" behavior.  And, complained to his buddies about it, who supported him.  He had a bad day at work; he almost got into a fight with his supervisor.  That night, he picked a fight with her so that he could storm out of the house and justify getting drunk at the bar.  Mitchell had repeated some version of this pattern innumerable times during their marriage.

After an extended period of sobriety from alcohol, marijuana, and cocaine use and despite the medical danger of drinking again, Gwyn relapsed with alcohol during her and Cybil's flight to Europe for a vacation.  She had also stopped using each time upon finding out she was pregnant.  For medical reasons Cybil could not get pregnant, so it was on Gwyn to bear children if they were to have a child with some biological inheritance from one of them.  She had stopped using during the pregnancies of all her children, with the intention of staying sober.  Over time, the stress of raising small children, financial problems, and conflict over her wife's self-righteous martyrdom caused her to become resentful.  Gradually, the feeling that she "deserved" to have fun (even though, substance use or alcohol had degenerated to anything but fun), led Gwyn to relapse.  Each time she had relapsed with an unacknowledged plan of beginning use and gradually increasing use after the babies grew old enough to be finished with breastfeeding.  She had remained abstinent longer this time, but the vacation to Europe became anticipated as a "vacation" from being "good".  She had actually begun craving alcohol seriously upon realizing that the plane flight would be twelve hours and that there would be drinks served.  Gwyn had begun then planning to drink… two months before the trip!

There are potential triggers and causes for relapse.  These become targets for therapeutic intervention.  The therapist should assess for common characteristics that are often of concern but not always identified as associated with addiction.  "Poor drinking outcomes have been associated with a variety of clinical and social characteristics, such as co-occurring depression, sleep disturbances, lower level of educational achievement, more previous hospitalizations for detoxification, family history of alcoholism, early-onset of alcohol dependence, being single, unemployment, and treatment drop-out.  Another important contribution to the understanding of alcohol relapse has been the influence of psychosocial stress in alcoholics.  According to the tension reduction hypothesis, alcohol-dependent individuals have learned to drink heavily to reduce stress and are likely to relapse if they are faced with stressors… From a neurobiological point of view, stress is seen as one of the most important triggers for relapse after a period of abstinence.  In clinical settings, severe psychosocial stressors, psychosocial vulnerability and self-efficacy were associated with relapse after treatment (Walter et al., 2006, page 101).  Exploration of family history and other characteristics along with historical, enduring, or current stressors can direct the therapist to diagnose addiction and predict relapse.

"Recovery work typically capitalizes on motivation by next turning attention to an intensive change- and growth-focused examination of subtle, seemingly minor lapses that have led to full-blown relapse in the past.  The intent of a forensic analysis of relapse risk factors is to explore elements specific to the partners' situation, and allow for an ongoing reevaluation of relapse warning signs, including relevant triggers, gateway thoughts and feelings, and first-step behaviors that increase the risk of relapse.  In this manner, mapping and analyzing risk factors allows the couple to retrace first steps that led to the addictive path and then regenerate conscious choice points where, in the future, exits from seemingly unavoidable relapse regression may occur (Seedall and Butler, 2008, page 81).  The therapist directs this examination through his or her questions.  The partner benefits from gaining greater understanding of the addict or recovering person's personal addictive process.  The world and experiences of the co-addict or partner has often been tumultuous, unpredictable, and incomprehensible.  Reviewing relapse or use helps validate the co-addict's experience and gives credibility to his or her feelings.  The non-addicted partner's sense of guilt and responsibility for addictive behaviors and relapse is placed in context of the addict's compulsions, manipulations, and distortions.  The shared analysis activates the couple's shared work of recovery not just from addiction, but also from co-addiction and of changing the addictive relationship.  The therapist helps ferret out the addict's actions and choices and the co-addict's actions and choices, and their interaction.  Blame and guilt are addressed so that each partner can take responsibility for his or her behaviors from before, in the present, and in the future.

Both partners often think that relapse happens suddenly without precedent, prior evolution, or gradual development.  The relapse often involves a gradual regression from stability that follows some ritualistic progression.  The building up of stress, pressures, feelings, choices, and so forth eventually reach a critical mass that trigger an automatic compulsive relapse response.  Going through enactments in therapy, gives the therapist opportunity to point out to the partners the factors, actions, or choices that lead to relapse: thoughts or cognitive conclusions, assumptions, or rationalizations ("stinkin' thinkin'"); problematic behaviors including rituals; emotional moods and physical conditions (anxiety, fatigue, etc.); and provocative environmental contexts or situations (conflict, family holidays, etc.).  Each partner can give nuance and perspective that the other individual may have missed.  The therapist may note and highlight subtle cues and interactions during enactments that amplify how their dynamics get intensified and distressing.  The ritualized nature of relapse can become clearer.  It is more impactful, when the therapist is able to get partners to speak candidly about each person's and their joint experience of relapse, feelings of hope and fear, and what they can do to reassure each other, increase hope, and promote recovery.  "The relapsing partner will have a more authentic and consequential awakening to the real threat and setback that relapse poses to relationship healing and trust.  S/he will experience the relational impact of the relapse, including the non-addicted partner's hurt, fear, heartache, and tears.  The non-addicted partner's experience of the relapse and accompanying pain can also be effectively coached within an enactment in order to facilitate partner validation of his/her experience.  As a result, both partners will have an opportunity to express relevant fears, remorse, anxiety, and desires while also seeking needed support and reassurance from each other" (Seedall and Butler, 2008, page 89).

ANTICIPATING AND PLANNING FOR RELAPSE
The therapist should be aware that the "…domestic situation, marital status, and pretreatment frequency of drinking days/month predict alcohol relapse far better than stress coping styles.  Unmarried alcoholics show a nearly twofold risk of relapse than married alcoholics.  No other variable contributes substantially to the prediction of drinking outcome in alcohol-dependent patients, nor did the stress coping styles assessed by the stress coping questionnaire" (Walter et al., 2006, page 103).  Social factors are important to outcomes of alcoholics attempting to stop use.  Being single versus being married and having lower education achievement are the best predictors of poor treatment outcomes.  Individuals with high social support were less likely to drink or drank less than those without such support.  Being married and living with someone versus being single and living by oneself affect risk for relapse.  These social factors appear to be more valuable in preventing relapse than stress coping styles, which have no measurable effect.  This implies that the therapist that enhances stress coping skills may not be particularly useful.  They may exacerbate personal shame and guilt for failing to resist using or behaving badly again despite having learned stress coping skills (page 104).  The utility of these findings in individual treatment may not be clear, but they have strong implications that couple therapy can build off of marital or partnership status and co-habitation.

Deconstructing prior progression to relapse may be very uncomfortable for the partners.  The instinct to deny or minimize the volitional quality of use or behavior could lead them to instead point to bad luck, unanticipated circumstances, and sudden illogical lapses.  The addict may complain that the review of prior relapses is not worthwhile.  It only serves to beat him or her down, encourages the partner to be more self-righteous, and increases shame.  The therapist should anticipate and plan to manage the addict's paranoia and accusations that the therapist and the non-addicted partner are being paranoid! The non-addicted partner is given a greater voice to characterize his or her experiences during the cycles of abstinence and progression to relapse.  The therapist while being prompting them for greater understanding honors both partners' experiences.  As the investigation is conducted as a joint co-operative process for joint recovery, the partners are encouraged to reconnect rather disconnect further.  The process becomes more couple-driven involving healing the relationship, as well as addressing addiction.  Both partners learn to become vigilant about early signs of relapse regression and triggers.   Beyond trying to prevent relapse, the therapist prepares the couple to deal with virtually inevitable relapse.  Planning for therapy and other attempts at change need not to be falsely optimistic.  While the addict and the partner hope for immediate effective intervention prompting permanent change, the fact and experience of addiction strongly predicts relapse.  Deconstructing relapse leads naturally to constructing plans for anticipation, prevention, and dealing with relapse.  "The couple can also outline a plan for managing actual relapses, including ways to establish a growth and learning perspective to relapse while also addressing relevant emotional responses and fears (e.g. 'Will I be abandoned if I relapse?'; 'Will you use this as a free pass for relapse?').  All of this provides the foundation for both partners to be empowered, as a recovery team, to guard against relapse while constantly working towards recovery" (Seedall and Butler, 2008, page 82).  The therapist gives voice to unspoken questions and anxieties that are intrinsic issues underlying their repeated promises, fears, and disappointments.  These are vital secrets to be revealed and addressed so that they can become a functioning team.

"Another factor in couples' overall shift in recovery approaches and attitudes was the development of collaborative 'watchtower' practices, clearly facilitated by conjoint therapy and contributing to recovery advances.  Labeling this 'watchtower work,' Craig described this as 'having someone else that can help you identify signs [of relapse],' or 'first steps' toward relapse.  He reported the helpfulness of having Carrie 'trying to block those first steps' and 'help[ing] me to see that [the first steps] are leading me down a path I don't want to be on.'  Adam commented that being in therapy together made it so that they 'were able to remind each other of stuff, especially her reminding me of stuff.'  Amy also added that 'we could say, 'Remember we learned this . . . we talked about that."'  (Zitzman and Butler, 2005, page 326).  The therapist needs to help the individual and the couple to identify the pattern and process of relapse, predict the continuation or replication of the pattern and process, and plan how to interrupt the pattern.  The plan needs to include how to avoid the self-sabotage that invariably occurs.  An effective plan anticipates the replication of the pattern when the individual or couple is unable to interrupt it.  The therapist can use failure to stop the pattern or relapse to reinforce the diagnosis of addictive behavior.  The acceptance of the diagnosis… the acceptance of the "label" then serves the foundation of change, as is often expressed in twelve-step programs.  The label of problematic use or problem behavior rather than of "addiction" may suffice as a form of diagnosis.  As stated earlier, getting too caught up in a precise label battle is often unproductive.  "You used again" or "You did it (the problematic behavior) again despite knowing it would not make things better and probably make things worse... Right?"  The therapist is not actually asking a question, but making a declarative statement and prompting the individual to accept it as accurate.  Getting the individual to accept this label of problematic use or behavior is sufficient temporarily to identify relapse and the compelling nature of the use or behavior.  With this increased insight and awareness, there is a greater likelihood of the relapse becoming a therapeutic relapse.  In other words, rather than being shamefully experienced only as a personal failure, relapse can become a therapeutic experience that used to further growth in recovery.  

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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