Understanding Relapse

By Terence T. Gorski

Relapse is more than just using alcohol or drugs. It is the progressive process of becoming so dysfunctional in recovery that self-medication with alcohol or drugs seems like a reasonable choice.

The relapse process is a lot like knocking over a line of dominoes. The first domino hits the second, which hits the third, and soon a progressive chain reaction has started.

The sequence of problems that lead from stable sobriety to relapse are similar to those dominoes. There are two differences. First, each domino in the line (i.e. each problem that brings us closer to substance use) gets a little bit bigger and heavier until the last domino in the sequence is ten feet tall, four feet wide, and a foot thick. As this 10,000 pound domino begins to fall on us, it is too heavy for us to handle alone. The second difference is that the dominoes circle around behind us. So when the last domino falls, it hits us from behind when we're not looking.

So here we are, moving along in recovery. We tip over one small domino. No big deal!  That domino hits the next, and then the next. A chain reaction gets started. The first dominoes are so small that we can easily convince ourselves that it's no big deal. We look the other way and start doing other things. All of a sudden a huge domino falls on us from behind, crushing us to the floor, causing serious pain and injury in the process. We need to make the pain go away and we reach for old reliable - the magical substances that always helped us with our pain in the past. We've now started drinking and drugging.

The answer to avoiding relapse is not to take up weight training so that we will be strong enough to lift that last domino off of our now crippled body. The first part of the answer is to learn how not to tip over the first domino. A second part of the answer is to develop an emergency plan for stopping the chain reaction quickly, before the dominoes start getting so big and heavy that they become unmanageable. A third part of the answer is to have an emergency plan for stopping relapse quickly should it occur.

The Relapse Process
The progression of problems that lead to relapse is called the relapse process. Each individual problem in the sequence is called a relapse warning sign. The entire sequence of problems is called a relapse warning sign list. The situations that we put ourselves in that cause or complicate the problems are caused high risk situations.

It's important to remember that we don’t start drinking and drugging because of the last problem in the sequence. We start drinking and drugging because the entire sequence of problems get out of control. Let's look at the steps of the relapse process in more detail.

Step 1: Getting Stuck In Recovery
Many of us decide that using alcohol or drugs is a problem. We stop using and put together a recovery plan to help us stay sober. At first we do fine. At some point, however, many of us hit a problem that we are unwilling or unable to deal with. We stop dead in our tracks. We are stuck in recovery and don’t know what to do.

Step 2: Denying that We’re Stuck
Instead of recognizing that we're stuck and asking for help, we use denial to convince ourselves that everything is OK. Denial makes it seem like the problem is gone, but it really isn't. The problem is still there. It just goes under ground where we can’t see it. At some level we know that the problem is there, but we keep investing time and energy in denying it. This results in a buildup of pain and stress.

Step 3: Using Other Compulsions
To cope with this pain and stress, we begin to use other compulsive behaviors. We can start overworking, over-eating, dieting, or over-exercising. We get involved in addictive relationships and distract ourselves by trying to experience the orgasm that shook New York City. All of these behaviors have one thing in common - they make us feel good in the short run by distracting us from our problems, but, since they do nothing to solve the problem, they make us feel worse in the long-run. We feel good now, but we hurt later. This is a hallmark of all addictive behaviors.

Step 4: Experiencing A Trigger Event
Then something happens. It's usually not a big thing. It’s something we could normally handle without getting upset. But this time something snaps inside. One person described it this way: "It feels like a trigger fires off in my gut and I go out of control." When the trigger goes off, our stress jumps up, and our emotions take control of our minds.

Step 5: Becoming Dysfunctional On The Inside
To stay sober we have to keep intellect over emotion. We have to remember who we are (an addicted person), what we can’t do (use alcohol or drugs), and what we must do (stayed focused on working a recovery program). When emotion gets control of our intellect, we abandon everything we know. We start trying to feel good now at all costs.

Relapse almost always grows from the inside out. The trigger event makes our pain so severe that we can't function normally. We have difficulty thinking clearly. We swing between emotional overreaction and emotional numbness. We can't remember things. It's impossible to sleep restfully and we get clumsy and start having accidents.

Step 6: Becoming Dysfunctional On The Outside
At first this internal dysfunction comes and goes. It's annoying, but it's not a real problem so we learn how to ignore it. The first small dominoes are starting to fall!  On some level, we know that something is wrong, so we keep it a secret. Eventually we get so dysfunctional on the inside that we start creating problems on the outside. We start making mistakes at work. We push away our friends, families, and coworkers. We start neglecting our recovery programs. And things keep getting worse.

Step 7: Losing Control
We handle each problem as it comes along but never look at the growing pattern of problems. We never really solve anything; we just put Band-aids on deep gushing cuts. We put first-aide cream on our seriously infected wounds. Then we tell ourselves that our problems are solved. We look the other way and get busy doing other things. We try to forget about the problems by getting involved in compulsive activities that we believe will somehow magically fix us.

This approach works for awhile, but eventually things start getting out of control. As soon as we solve one problem, two new problems pop up to replace it. Life becomes one problem after another in an apparently endless sequence of crisis. One person put it like this: "I feel like I'm standing chest deep in a swimming pool trying to hold three beach balls underwater at once. I get the first one down, then the second, but as I reach for the third, the first one pops back up again." 

We finally recognize that we're out of control. We get scared and angry. "I'm sober! I'm not drinking! I'm working a program! Yet I'm out of control. If this is what sobriety is like - who needs it?"

Step 8: Using Addictive Thinking
Now we go back to using addictive thinking. We begin thinking along these lines: “Sobriety is bad for me, look at how miserable I am. Sober people don’t understand me. Look at how critical they are. Maybe things would get better if I could talk to some of my old friends. I don’t plan to drink or use drugs, I just want to get away from things for awhile and have a little fun. People who supported my drinking and drugging were my friends. They knew how to have a good time. These new people who want me to stay sober are my enemies. Maybe I was never addicted in the first place. Maybe my problems were caused by something else. I just need to get away from it all for awhile! Then I'll be able to figure it all out."

Step 9: Going Back To Addictive People, Places, and Things
Now we start going back to addictive people (our old friends), addictive places (our old hangouts), and addictive things (mind polluting compulsive activities). We convince ourselves that we're not going to drink or use drugs. We just want to relax.

A client in one of my groups said he wanted to go to a bar so he could listen to music and relax while drinking soft drinks. And old timer in the group asked: "If you told me you were going to a whore house to say prayers, do you think I'd believe you?  Well, when you tell me you're going to a bar to drink cokes, I have about the same reaction!"

Step 10: Using Addictive Substances
Eventually things get so bad that we come to believe that we only have three choices - collapse, suicide, or self-medication. We can collapse physically or emotionally from the stress of all our problems. We can end it all by committing suicide.  Or we can medicate the pain with alcohol or drugs. If these are the only three choices, which one sounds like the best way out?

At this stage the stress and pain is so bad that it seems reasonable to use alcohol or drugs as a medicine to make the pain go away. The 10,000 pound domino just struck the back of our head, breaking our bones, and crushing us to the ground. We're dazed, hurt, and in tremendous pain. So we reach out for something, anything that will kill the pain. We start using alcohol and drugs in the misguided hope it will make our pain go away.

Step 11: Losing Control Over Use
Once addicted people start using alcohol or drugs, they tend follow one of two paths. Some have a short term and low consequence relapse. They recognize that they are in serious trouble, see that they are losing control, and manage to reach out for help and get back into recovery.

Others start to use alcohol or drugs, feel extreme shame and guilt, and refuse to seek help. They eventually develop progressive health and life problems and either get back into recovery, commit suicide, or die. Death from addictive relapse is not pleasant. It usually takes the form of medical complications, accidents, or drug-related violence.

Other Outcomes Of The Relapse Process
Some us will experience all of these problems, but never start drinking or drugging. We may say "I'd rather be dead than drunk" and attempt suicide. We may just hang in there until we have a stress collapse, develop a stress related illness, or have a nervous breakdown. Or we might use half measures to temporarily pull ourselves together for a little while only to have the problems come back later. This is called partial recovery and many people stay in it for years. They never get really well, but they never really get drunk either.

What I have just described is called the relapse process and it's not rare. Most recovering people periodically experience some of these warning signs. About half can stop the process BEFORE they start using substances or collapse from stress. The other half revert to using alcohol or other drugs, collapse from stress related illness, or kill themselves.

It's not a pretty picture. No wonder we don't want to think or talk about relapse. It's depressing. The problem is that refusing to think or talk about it doesn't stop it from happening. As a matter of fact ignoring the early warning sing makes us more likely to relapse.

But there is hope. There is a method called Relapse Prevention that can teach us to recognize early warning signs of relapse and stop them before we use alcohol and drugs or collapse. That's what my next article is about. There's also a process called Relapse Early Intevervention that helps us to set up an emergency plan to stop relapse quickly should it occur. We'll cover that in our third article.

Relapse Prevention Counselling (RPC) is available as a two-day intensive seminar and is being offered by Lifeworks Community on 2-3 October 2006 at RegentsCollege, London. For more information on training please contact Life Works Community Ltd. Tel: +44 (0) 1483 757 572, email: elinzell@lifeworkscommunity.com or log onto www.lifeworkscommunity.com

References
Gorski, Terence T., and Miller, M., Staying Sober - A Guide for Relapse Prevention. Independence, Missouri, Herald House/Independence Press, 1986.
Gorski, Terence Gorski, T., Passages Through Recovery - An Action Plan for Preventing Relapse. Center City, Minnesota, Hazelden, 1989.
Gorski, Terence T., How to Start Relapse Prevention Support Groups. Independence, Missouri: Herald House/Independence Press, 1989.
Gorski, Terence T., Relapse - Relapse Prevention - A New Recovery Tool, Alcoholism & Addiction Magazine. September 25, 1989  (CENREF ART001)