By Terence T. Gorski
GORSKI-CENAPS Web Publications www.cenaps.com www.relapse.org
August 8, 3016 (Updated from May 28, 2003)
People who relapse aren’t suddenly taken drunk. Most experience progressive warning signs that reactivate denial and cause so much pain and so many problems that self-medication with alcohol or other drugs (AODS) seems like a good idea.
These warning signs are not a consciously created. They develop automatically and unconsciously.
Since most recovering people have never been taught how to identify and manage relapse warning signs, they don’t notice them until the pain and problems become too severe to ignore. This is often too late. The pain and problems have activated addictive thinking and drug seeking behavior that is difficult to stop.
The progressive addiction process causes addicts to developed deeply entrenched habits of coping with pain and problems by self-medicating with AODS. They don’t make the decision to self-medicate consciously. They go on automatic pilot and the deeply entrenched habits of addictive thinking and alcohol/drug seeking behavior kick in.
They focus on “not using” because they mistakenly believe that their addiction lives in the alcohol alcohol and other drugs. If they just make a decision to stop and tough it out through the first few days of sbstinrmce they will feel better and their life will automatically return to normal. In other words, they decide to get sober using will power alone. This is often called “white knuckle sobriety” because it is a painful process of holding onto abstinence by hanging on with your finger tips
Unfortunately this doesn’t work. The longer they grit their teeth and force themselves “not to drink or use drugs” the higher their stress gets. High stress increases their pain and problems and wipes out their thinking and problem solving skills.
The only way most addicts know how to manage pain and solve problems is by self-medicating their distress by using AODS. “Besides,” they tell themselves. “I made a commitment not to drink or use drugs. So I won’t.” A part of them knows that this won’t work. They have been here and done before. “But this time,” they tell themselves, “things will be different.” So they grit their teeth and set their mind on not drinking or drugging. They refuse to change their thinking or how they manage their feelings and behavior.
In other words, they keep thinking, managing their feelings, acting, and relating to others the same way they did when they were using. The only difference is they stopped using.
They never learned other ways to manage stress, pain and problems without using. They thought this would just happen automatically when they stopped using. They never considered that addiction does not live in the alcohol or drugs they use.
Addiction lives in within us and around us in many different ways. Addiction lives the way we think and the way we manage our feelings. It lives in the way we act and how we relate to other people. It lives in the places we go and in the things we do and don’t do. It lives and things we surround ourselves with. Our addiction lives in the addictive values we guide our lives by and the alcohol and drug centered social networks we have built.
So we keep thinking, feeling, and acting like a drunk or an active drug addict but we stop using. We keep surrounding ourselves with people who drink and use drugs but we stop using. We never consider that we need to learn a new set of sober and responsible life skills and develop a new sobriety-centered lifestyle.
So the stress and pain builds up inside of us. We mismanage our lives and the problems we encounter. We deny how badly things are going and how much pain we are feeling. It doesn’t take long before we are feeling so bad that we ask ourselves “if this is sobriety, who wants it?”
We start to think that at least when we were drinking and drugging we had moments of feeling good and periods of escape from the stress, pain, and problems of life. When not using the pain and problems are always there.
Things keep getting worse until we hurt so bad we mistakenly believe that we only have three choices:
- To keep forcing ourselves to carry on until we collapse from stress or stress-related physical or mental health problems;
- To end the pain by committing suicide,or
- To self-medicate with AODS to end the pain.
If we decide to self-medicate, we convince ourselves that this time it will be different. This time we will control our drinking and drugging better than we did before. Deep inside of us is a sober sand responsible part of ourselves telling us not to do this because it won’t work.
The truth is that no matter how bad things get in sobriety there is always another choice we can make. We don’t have to self-medicate with alcohol or other drugs. We can develop a Relapse Prevention (RP) Plan by identifying exactly how we created the pain and problems lea us back into addictive use. Then we can identify where we can stop this process of building up to drink by making a detailed Relapse Prevention (RP) Plan. To be effective this plan must include a clear picture of the sequence of relapse warning signs that leaf us back into addictive use. Three places in this progression where we can stop the process. We can identify new and more effective ways of thinking, feeling, acting, and relating to others that will break this process of building up to drink/drug. We can practice using these relapse prevention skills before we are in a crisis. We can be prepared to interrupt the progression of relapse warning signs so we can stop the process before we start drinking or drugging. This means that we need to develop a Relapse Prevetion Plan.
The Relapse Prevetion Plan
There are nine steps in learning how to recognize and stop the early warning signs of relapse. Let’s review the nine steps of the RP planning process in more detail.
Step 1: Stabilization:
Relapse prevention planning probably won’t work unless the relapser is sober and in control of themselves. Detoxification and a few good days of sobriety are needed in order to make relapse prevention planning work.
Remember that many people who relapse are toxic. Even though sober they have difficulty thinking clearly, remembering things and managing their feelings and emotions. These symptoms get worse when the person is under high stress or is isolated from people to talk to about the problems of staying sober.
This is not the time to do intense psychotherapy that digs up painful memories from childhood. This will come latter in recovery when the relapse solid recovery and relapse prevention plan that gives them the skills and support they need to stay sober one day at a time. Many relapsers are late stage addicts and have a toxic brain that can increase rather than decrease the risk of relapse. In early abstinence it is important to go slowly and focus on basic recovery skills The key question is “What do you need to do to not drink today?”
Step 2: Assessment:
The assessment process is designed to identify the recurrent pattern of problems that caused past relapses and resolve the pain associated with those problems.
This is accomplished by writing down the presenting problems and how those problems are related to their addiction. It also involves guiding the person through a life history, the alcohol and drug use history and the recovery relapse history.
By reconstructing the presenting problems the here and now issues that pose an immediate threat to sobriety can be identified and crisis plans developed to resolve those issues.
The life history explores each developmental life period including childhood, grammar school, high school, college, military, adult work history, adult friendship history, and adult intimate relationship history. Reviewing the life history can surface painful unresolved memories. It’s important to go slow and talk about the feelings that accompany these memories.
Once the life history is reviewed, a detailed alcohol and drug use history is reconstructed. This is be done by reviewing each life period and asking four questions:
1. How much alcohol or drugs did you use during this life period?
2. How often did you use during this life period?
3. What did you want alcohol and drug use to do for you that you couldn’t do without it? and
4. What were the real consequences, both positive and negative, of your use? In other words, did the booze and drugs do for you what you wanted it to do during each period of your life?
Finally, the recovery and relapse history is reconstructed. Starting with the first serious attempt at sobriety each period of abstinence and AOC use is carefully explored.
The goal is to find out what happened during each period of abstinence that set the stage for renewed AOD use. This is often difficult because most relapsers are preoccupied with their drinking and drugging and resist thinking or talking about what happened during periods of abstinence. Some people use euphoric recall to romanticize their use. They lock onto and exagerrate the good times of an episode of AOD use and blocking out the pain and the problems.
Comprehensive assessments have shown that most relapsers get sober, encounter the same recurring pattern of problems, and use those problems to justify the next relapse. As one person put it “It is not one thing after the other, it is the same thing over and over again!”
A 23 year old relapser named Jake reported drinking about a six pack of beer every Friday and Saturday night during high school. He did it in order to feel like he was part of the group, relax and have fun. At that stage in his addiction the beer did exactly what he wanted it to do.
That all changed when Jake left school and went to work as a salesman. He had to perform in a high pressure environment and felt stressed. The other salesmen were competitive and no matter what he did they wouldn’t let him belong. He began drinking bourbon every night to deal with the stress. He wanted to feel relaxed so he could cope better at work. He consistently drank too much and woke up with terrible hangovers that caused new problems with his job.
Every time Jake would attempt to stop drinking he would feel isolated and alone and become overwhelmed by the stress of his job. Even when with others at Twelve Step Meetings he felt like he didn’t belong and couldn’t fit in. As the stress grew he began to think “If this is sobriety who needs it?” Each relapse was related with his inability to deal with job related pressures.
By comparing the life history, the alcohol and drug use history, and the recovery relapse history Jake could see in a dramatic way the recurrent problems that caused him to relapse. The two major issues were (1) the need to drink in order to feel like he belonged and (2) the need to drink in order to cope with stress.
It wasn’t surprising that Jake discovered that during every past period of abstinence he became isolated, lonely and depressed. The longer he stayed sober the worse it got. The stress built up until he felt that if he didn’t take a drink to relax he would go crazy or collapse.
Step 3: Relapse Education:
Relapsers need to learn about the relapse process and how to manage it. It’s not a bad idea to get their family and Twelve Step Sponsors involved. The education needs to reinforce four major messages: First, relapse is a normal and natural part of recovery from chemical dependence. There is nothing to be ashamed or embarrassed about. Second, people are not suddenly taken drunk. There a progressive patterns of warning signs that set them up to use again. These warning signs can be identified and recognized while sober. Third, once identified recovering people can learn to manage the relapse warning signs while sober. And Fourth, there is hope. A new counseling procedure called relapse prevention therapy can teach recovering people how to recognize and manage warning signs so a return to chemical use becomes unnecessary.
When Jake entered relapse prevention therapy he felt demoralized and hopeless. That began to change when he heard his first lecture that described the typical warning signs that precede relapse to chemical use. He felt like someone had read his mail. “Since someone understand what causes me to get drunk,” he thought, “perhaps they know what to do in order to stay sober.
Step 4: Warning Sign Identification:
Relapsers need to identify the problems that caused relapse. The goal is to write a list of personal warning signs that lead them from stable recovery back to chemical use.
There is seldom just one warning sign. Usually a series of warning signs build one on the other to create relapse. It’s the cumulative affect that wears them down. The final warning sign is simply the straw that breaks the camel’s back. Unfortunately many of relapsers think it’s the last warning sign that did it. As a result they don’t look for the earlier and more subtle warning signs that set the stage for the final disaster.
When Jake first came into relapse prevention therapy he thought that he was crazy. “I can’t understand it,” he told his counselor, “Everything was going fine and suddenly, for no reason at all I started to overreact to things. I’d get confused, make stupid mistakes and then not know what to do to fix it. I got so stressed out that I got drunk over it.”
Jake, like most relapsers, didn’t know what his early relapse warning signs were and as a result didn’t recognize the problems until it was too late. A number of procedures are used to help recovering people identify the early warning signs relapse.
Most people start by reviewing and discussing The Phases And Warning Signs Of Relapse (available from Independence Press, PO Box HE, Independence MO 64055, 1-800-767-8181). This warning sign list describes the typical sequence of problems that lead from stable recovery to alcohol and drug use. By reading and discussing these warning signs relapsers develop a new way of thinking about the things that happened during past periods of abstinence that set them up to use. They learn new words with which to describe their past experiences.
After reading the warning signs they develop an initial warning sign list by selecting five of the warning signs that they can identify with. These warning signs become a starting point for warning sign analysis. Since most relapsers don’t know what their warning signs are they need to be guided through a process that will uncover them. The relapser is asked to take each of the five warning signs and tell a story about a time when they experienced that warning sign in the past while sober. They tell these stories both to their therapist and to their therapy group. The goal is to look for hidden warning signs that are reflected in the story.
Jake, for example, identified with the warning sign “Tendency toward loneliness.” He told a story about a time when he was sober and all alone in the house because his wife had left with the children. “I felt so lonely and abandoned, he said. I couldn’t understand why she would walk out just because we had a fight. She should be able to handle it better than she does.”
The group began asking questions and it turned out that Jake had frequent arguments with his wife that were caused by his grouchiness because of problems on the job. It turned out that these family arguments were a critical warning sign that occurred before most relapses. Jake had never considered his marriage to be a problem, and as a result never thought of getting marriage counseling.
Jake had now identified three warning signs: (1) the need to drink in order to feel like he belonged, (2) the need to drink in order to cope with stress, and (3) the need to drink in order to cope with marital problems. In order to be effectively managed each of these warning would need to be further clarified.
I then had Jake to write these three warning signs using a standard format and identify the irrational thoughts, unmanageable feelings and self defeating behavior that accompanied each. He wrote:
(1) I know I am in trouble with my recovery when I feeling lonely and unable to fit in with other people; When this happens I tend to think that I am no good and nobody could ever care about me. When this happens I tend to feel lonely, angry and afraid. When this happens I have an urge to hide myself away so I don’t have to talk with anyone.
(2) I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress; When this happens I tend to think that I need to try harder in order to get things under control or else I will be a failure. When this happens I tend to feel humiliated and embarrassed. When this happens I drive myself to keep working even thought I know I need to rest.
(3) I know I am in trouble with my recovery when I irrationally angry at my wife. When this happens I tend to think that I’m a terrible person for treating her that way, but a part of me believes she deserves it. When this I happens I tend to feel angry and ashamed. When this happens forget that the incident ever happened, put it behind us and get on with our marriage.
With this detailed description of the relapse warning signs Jake was ready to move on to the fifth step of relapse prevention planning, warning sign management.
Understanding the warning signs is not enough. We need to learn how to manage them without resorting to alcohol or drug use. This means learning nonchemical problem solving strategies that help us to identify high risk situations and develop coping strategies. In this way relapsers can diffuse irrational thinking, manage painful feelings, and stop the self-defeating behaviors before they lead to alcohol or drug use.
This is done by taking each relapse warning sign and developing a general coping strategy. Jake, for example developed the following management strategy for dealing with his job related stress.
Warning Sign: I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress.
General Coping Strategy: I will learn how to say no to taking on extra projects, limit my work to 45 hours per week, and learn how to use relaxation exercises and meditation to unwind.
The next step is to identify ways to cope with the irrational thoughts, unmanageable feelings, and self-defeating behaviors that accompany each warning sign. Jake developed the following coping strategies:
Irrational Thought: I need to try harder in order to get things under control or else I will be a failure.
Rational Thought: I am burned out because I am trying to hard. I need to time to rest or I will start making more mistakes.
Unmanageable Feelings: Humiliation and embarrassment.
Feeling Management Strategy: Talk about my feelings with others. Remind myself that there is no reason to embarrassed. I am a fallible human being and all people get tired.
Self-defeating Behavior: Driving myself to keep working even thought I know I need to rest.
Constructive Behavior: Take a break and relax. Ask someone to review the project and see if they can help me to solve the problem.
Now Jake is ready to move unto the sixth step of recovery planning. A recovery plan is a schedule of activities that puts relapsers into regular contact with people who will help them to avoid alcohol and drug use. They must stay sober by working the twelve step program and attending relapse prevention support groups that teach them to recognize and manage relapse warning signs. This is why I call relapse prevention planning a “Twelve Step Plus” approach to recovery.
Jake needed to build something into his recovery program to help him deal with job related stress. He decided to enter into counseling with a counselor who specialized in stress management, understood chemical dependency and had a background as an employee assistance counselor. By doing this Jake was forced to regular discuss his problems at work and review how he was coping with them. By identifying job related problems early, he could prevent getting overwhelmed by small problems that became overwhelming.
The seventh step is inventory training. Most relapsers find it helpful to get in the habit of doing a morning and evening inventory. The goal of the morning inventory is to prepare to recognize and manage warning signs. The goal of the evening inventory is to review progress and problems. This allows relapsers to stay anticipate high risk situations and monitor for relapse warning signs. Relapsers need to take inventory work seriously because most warning signs are deeply entrenched habits that are hard to change and tend to automatically come back whenever certain problems or stresses occur. If we aren’t alert we may not notice them until it’s too late.
The eighth step is family involvement. A supportive family can make the difference between recovery and relapse. We need to encourage our family members to get involved in Alanon so they can recover from codependency. With this foundation of shared recovery we can beginning talking with our families about past relapses, the warning signs that led up to them, and how the relapse hurt the family. Most importantly we can work together to avoid future relapse.
If we had heart disease we would want our family to be prepared for an emergency. Chemical dependency is a disease just like heart disease. Our families’ needs to know about the early warning signs that lead to relapse. They must be prepared to take fast and decisive action if we return to chemical use. We can work out in advance, when we are in a sober state of mind, the steps they should take if we return to chemical use. Our very life could depend upon it.
The final step is follow-up. Our warning signs will change as we progress in recovery. Each stage of recovery has unique warning signs. Our ability to deal with the warning signs of one stage of recovery doesn’t guarantee that we will recognize or know how to manage the warning signs of the next stage. Our relapse prevention plan needs to be updated regularly; monthly for the first three months, quarterly for the first two years, and annually thereafter.
Originally Published In: Alcoholism & Addiction Magazine: Relapse – Issues and Answers: Column 3: How To Develop A Relapse Prevention Plan: By Terence T. Gorski, September 25, 1989; 708-799-5000, http://www.cenaps.com.
About the Author
Terence T. Gorski is internationally recognized for his contributions to Relapse Prevention Therapy. The scope of his work, however, extends far beyond this. A skilled cognitive behavioral therapist with extensive training in experiential therapies, Gorski has broad-based experience and expertise in the chemical dependency, behavioral health, and criminal justice fields.
To make his ideas and methods more available, Gorski opened The CENAPS Corporation, a private training and consultation firm of founded in 1982. CENAPS is committed to providing the most advanced training and consultation in the chemical dependency and behavioral health fields.
Gorski has also developed skills training workshops and a series of low-cost book, workbooks, pamphlets, audio and videotapes. He also works with a team of trainers and consultants who can assist individuals and programs to utilize his ideas and methods.
Terry Gorski is available for personal and program consultation, lecturing, and clinical skills training workshops. He also routinely schedules workshops, executive briefings, and personal growth experiences for clinicians, program managers, and policymakers.
Mr. Gorski holds a B.A. degree in psychology and sociology from Northeastern Illinois University and an M.A. degree from Webster’s College in St. Louis, Missouri. He is a Senior Certified Addiction Counselor In Illinois. He is a prolific author who has published numerous books, pamphlets and articles. Mr. Gorski routinely makes himself available for interviews, public presentations, and consultant. He has presented lectures and conducted workshops in the U.S., Canada, and Europe.
For books, audio, and video tapes written and recommended by Terry Gorski contact: Herald House – Independence Press, P.O. Box 390 Independence, MO 64055. Telephone: 816-521-3015 0r 1-800-767-8181. His publication website is http://www.relapse.org.
Terry Gorski and other members of the GORSKI-CENAPS Team are available to train & consult on areas related to recovery & relapse prevention