Relapse Process, By Andrew T Martin, MBA, LAADC, SAP, CA-CCS

relapse simplified

The clinical definition of relapse is when a person is affected again by a condition that affected them in the past. By definition, for relapse to happen, the disease must have been in remission or cured. In the case of addiction, the disease is incurable (chronic), however the disease can be put into remission.

Relapse is often thought of as an event, such as taking a drink or using a drug: however relapse is actually an extended process that begins long before the use of a chemical substance. There are significant and identifiable phases of relapse.

Terrence Gorski and Merlene Miller collaborated on the development of eleven phases of relapse. If an addict is self‐aware and informed on these phases, it is possible to intervene at any point in the relapse process in order to return to the state of remission.

It is possible to intervene at any point in the relapse process in order to return to the state of remission.

Phase 1: Internal Change
Looking good on the outside, but beginning to use unhealthy and addictive thinking to manage feelings of negative self‐image. Intervene if some of the following warning signs are present:

•Increased stress – can be due to a major circumstance or little things building up.

•Change in thinking – working a recovery program is not as important any more.

•Change in feelings – mood swings and exaggerated positive or negative feelings.

•Change in behavior – not working a program like before, knowing something is wrong.

Phase 2: Denial
I begin to overlook what I am thinking and feeling, and I stop honestly telling others what I am thinking and feeling. Intervene if some of the following warning signs are present:

•Worrying about myself – feeling afraid of using drugs, and dismissing the fear because the thought is too uncomfortable.

•Denying that I am worried – persuading one’s‐self that everything is OK, when it really is not.

Phase 3: Avoidance and Defensiveness
Avoiding anyone or any situation that will force the honest evaluation of one’s thinking, feelings and changes in behaviors: and if confronted, being defensive and not listening. Intervene if some of the following warning signs are present:

•Believing alcohol or drugs will never be used again – convincing one’s‐self that not much energy is needed to maintain sobriety, and keeping this though a secret.

•Worrying about others – focusing more on the sobriety of others than on one’s‐self, judging other’s programs, and keeping it all a secret.

•Defensiveness – avoiding discussions of personal problems for fear of being criticized or confronted.

•Compulsive behavior – reverting to old, rigid and self‐defeating ways of thinking and acting.

•Impulsive behavior ‐ using poor judgment and causing problems due to impulsive behavior without thinking things through.

•Avoiding people – feeling uncomfortable around others and changing behavior to be alone, making excuses not to socialize, and feeling lonely.

Phase 4: Crisis Building
Working hard to solve problems but seemingly having two new problems arise for every one solved. Intervene if some of the following warning signs are present:

•Tunnel vision – focusing on one small part of life to the exclusion of everything else.

•Minor depression – feeling down, sleeping too much and lacking energy without talking about the mood depression.

•Loss of constructive planning – not looking ahead or thinking about what to do next.

•Plan failure – plans begin to fail and each failure causes an overreaction creating new problems and feelings of guilt and remorse.

Phase 5: Immobilization
Feeling trapped in an ongoing stream of unmanageable problems and feeling unmotivated to take action. Intervene if some of the following warning signs are present:

•Wishful thinking – having fantasies of escape or rescue if only a person will help or an event will happen.

•Defeat – feeling like a failure, someone who cannot get anything right.

•Immature wish to be happy – desire to be happy but have no idea how to make it happen or any will to make it happen.

Phase 6: Confusion and Overreaction
Trouble with thinking clearly and managing thoughts, feelings and actions. Intervene if some of the following warning signs are present:

•Difficulties thinking clearly – usually simple problems are perplexing due to a mental shut down or an uncontrolled frenzy of thought.

•Difficulty managing feelings and emotions – overreacting or feeling numb, crazy thoughts.

•Difficulty remembering – remembering things from the past can be difficult at times and learning new things can be a challenge.

•Confusion – periods of not knowing what is right or wrong, healthy or unhealthy, and not knowing how to solve a problem.

•Stress mismanagement – feeling numb and not recognizing it, feeling overwhelmed for no apparent reason, not being able to relax regardless of the situation or environment.

•Strained relationships – being annoyed when friends, family, counselors and others in recovery talk about changes they see in my behavior and mood; or not caring what they say.

•Anger – loss of temper for illegitimate reasons and feeling guilty afterward.

Phase 7: Depression
Feeling, at times, that life is not worth living or thinking about self‐medicating with drugs or alcohol to avoid the depression. Intervene if some of the following warning signs are present:

•Irregular eating – overeating or loss of appetite, replacing healthy meals with junk food.

•Unmotivated – not being able to get started or get anything done and feeling trapped.

•Difficulty sleeping – not able to fall asleep, having disturbing dreams and un‐restful sleep.

•Loss of daily structure – daily routine becomes haphazard.

•Deeply depressive periods – depression is noticed by others and cannot be easily denied, feeling that nobody cares or understands.

Phase 8: Behavioral Loss of Control
Inability to control one’s thoughts, feelings and behaviors. Intervene if some of the following warning signs are present:

•Irregular attendance at meetings – finding justified excuses not to go to therapy meetings, self‐help meetings and to meet with a sponsor. Making other things more important.

•Unconcerned attitude – not caring about problems in order to hide feelings of hopelessness.

•Rejection of help – actively cut off people who can help.

•Dissatisfaction with life – Feeling like going back to alcohol and drugs because things can’t get any worse.

•Powerlessness – Feeling as if there is nothing that can be done and there is no way out.

Phase 9: Recognition of Loss of Control
Denial breaks down and a realization occurs that life is unmanageable, problems are severe, and there is little control over circumstances. Fear and anxiety result due to isolation and a feeling there is no one to turn to for help. Intervene if some of the following warning signs are present:

•Difficulty with physical coordination – dizziness, poor balance, hand‐eye coordination and slow reflexes cause clumsiness and accidents.

•Self‐pity – believing that there is no hope and feeling sorry for one’s self.

•Thoughts of social use – hoping that returning to social drinking and recreational drug use can be controlled and may be the only alternative for feeling better.

•Conscious lying – lying with the knowledge that things being said are lies, and not being able to stop lying.

•Loss of self‐confidence – believing one’s self is useless, incompetent and will never be able to manage life.

Phase 10: Option Reduction
Believing there are only three ways out: insanity, suicide, or self‐medication with alcohol and/or chemical substances. Intervene if some of the following warning signs are present:

•Unreasonable resentment – anger resulting from the inability to behave in unhealthy ways.

•Discontinuance of treatment – stops attending all meetings with counselors and self‐help groups and discontinues any pharmacotherapy treatments.

•Overwhelming loneliness, frustration, anger and tension – feeling helpless, desperate and about to go crazy.

•Loss of behavioral control – inability to control thoughts, emotions, and judgments.

Phase 11: Alcohol and Drug Use
Return to alcohol and/or chemical substance use and quickly lose control. Intervene if some of the following warning signs are present:

•Attempting controlled use – plan to use socially or short‐term.

•Disappointment, shame and guilt – the alcohol and drug use do not produce the desired results and disappointment is followed by shame and guilt due to the relapse.

•Loss of control – alcohol and chemical substance use spirals out of control.

•Life and health problems – quality of life plummets as severe problems with relationships, jobs, finances, mental and physical health grow to require professional treatment.

Relapse Intervention
At the first sign of a potential relapse symptom, follow the following intervention steps:

1.Identify the Problem – explore what is really going on, think accurately and candidly.

2.Clarify the Problem – in concrete and specific terms, describe the problem in detail.

3.Identify Alternatives – determine different ways the problem can be addressed, write down several options. If the problem cannot be solved, work on acceptance.

4.Examine the Alternatives – what are the consequences for each potential action?

5.Decision – make a commitment.

6.Action – make a plan of action and implement it.

7.Evaluation – is the plan of action working or does it need modification?

8.Accountability – share the plan of action with a sponsor or friend and ask them to help monitor progress.

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Andrew Martin