According to the National Institute on Drug Abuse, addiction is defined as “a chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain.”
Relapse is a common experience for many people with substance use disorder (SUD). That makes addiction similar to other chronic diseases. As with SUD, patients with chronic illnesses such as diabetes, asthma, and hypertension frequently fail to comply with their treatments and relapse, so to speak, sometimes with serious consequences.
Although many SUD patients experience a relapse, it should ideally be avoided, of course. Relapse prevention is an important element of addiction treatment. In her recent presentation as part of the Williamsburg Place Lecture Series, Barbara Mardigian looked at the most important aspects of relapse prevention. Mardigian is the deputy clinical director of the Virginia Judges and Lawyers Assistance Program.
The first problem with the chronic, relapsing disorder is that it still carries a lot of stigma—even in the treatment community. Therapists treating people with SUD should be aware of their own biases, warned Mardigian and always remember that it is a disease, not a moral defect. She once heard somebody say on TV, “I don’t like heroin addicts, I think they are weak.” It turned out to be somebody who actually referred people to treatment.
Many people still ask, “why can’t they just stop using?” when confronted with addiction since they don’t understand that the addicted person has no control over their substance use behavior. “It’s not a matter of willpower,” said Mardigian. “If you have diarrhea, try using your willpower to make it stop. That makes about as much sense as telling an addict in active addiction to use their willpower to stop using.”
Relapse is a Process
According to addiction expert, Terence T. Gorski “relapse is the process of becoming dysfunctional in recovery.” This is a very important point, said Mardigian. “It’s a process and using is only the last step.” Gorski was the first one who talked about exploring relapse triggers and explored how to interrupt the relapse process as much as possible.
Recognizing relapse warning signs is an important element of that effort. Old self-defeating thought patterns might return, clients might appear unusually agitated, or talk about hanging out with toxic people unsupportive of their recovery. All of these may occur long before there is substance use again. Relapses build up in small incremental steps that are seemingly unimportant at the time. Mardigian quoted addiction expert Kevin McCauley who said: “Addiction is not the result of one big decision, but several little decisions.” That also applies to relapse.
Terence Gorski developed nine basic principles for his CENAPS model of relapse prevention therapy. The first one deals with self-regulation. People with addiction initially don’t know how to self-regulate; in recovery, they have to learn it or face relapse. Self-regulation is also a process, people in recovery have to work on every day. It is a chronic disease after all.
Gorski’s nine principles are:
- Coping skills
Understanding the disease and its triggers, acquiring coping skills, making changes according to a recovery plan, and having the support of friends and family all strengthen recovery and help prevent a relapse.
It’s also important to overcome unrealistic expectations on all sides because they can be dangerous. Recovery is a daily struggle and not at all a straightforward path. A relapse should just be a temporary setback not a reason to give up.
After a relapse, Mardigian tends to analyze the course of the relapse with the client to avoid another one. What warning signs were missed? At what point could we have intervened earlier?
At the end of the presentation, Mardigian stressed the importance of recovery allies. Find out who is in your corner, who won’t use shaming and support you regardless.
Recovery from addiction is a long and winding road, full of detours and disappointments. It will not be a walk on a sunny beach but recovery is always possible even after a relapse.