Terminal Illness and Relapse: Why Stay Sober If You’re Dying?

November 22, 2013

Untitled1By Terence T. Gorski
www.relapse.org — www.facebook.com/GorskiRecovery — www.cenaps.com

I had just completed a workshop on relapse prevention. As I was leaving the conference room, a thin and frail-looking man from the audience approached me.  In a voice tinged with quiet desperation, he asked if he could talk with me privately. We moved to the side of the conference room, pulled up a couple of chairs, and sat down to talk.

“Mr. Gorski,” he said, “My name is Malcolm. I am recovering from chemical dependence and have been sober for nearly eleven years. I’ve had AIDS now for over two years and I’m beginning to get very sick and I know I will die. A big part of me wants to start drinking to deal with it and, to be quite frank, considering my condition, I can’t think of any good reasons to stay sober. What should I do?”

Many counselors are asked this question. Their clients struggled to get sober, only to become a statistic in the growing in the growing AIDS epidemic. Other sober people also ask this question when, in sobriety, they are diagnosed with cancer or other chronic and fatal diseases. Many of these people find the courage to face their death in sobriety.  Others return to alcohol or drug use. Of those who relapse, some get back into recovery and die sober, but many others die a horrible death from the combination of AIDS and out of control chemical addiction.

What can we say to these people?  How can we convince them that it is in their best interest to stay in recovery in spite of the horrors of their disease. How can we give them the courage to face their death sober? Should we even try? If an addict is dying, why should he or she stay sober? I can think of many good reasons for staying sober in the face of death.

Alcohol and Drugs Won’t Help!

It is tempting for terminally ill patients to believe the mistaken notion that alcohol and drug use will somehow make their disease easier to cope with. It does not.  I ask patients to think back to the times when they were using alcohol and drugs and to remember the quality of their lives.

No matter how painful or debilitating your terminal illness may be, alcohol and drugs will only make it worse.  The mental anguish and pain you may be experiencing will increase and your ability to cope with your disease will progressively disappear.  At best, alcohol and drugs will provide brief moments of temporary anesthesia, followed by periods of shame, guilt, and dysfunction.  As the chemical dependency progresses, and it always progresses, the resultant loss of control will prevent you from responsibly treating your illness, destroy any hope of having quality moments of life, and escalate your movement toward a painful death.

For people who are addicted, alcohol and drugs are never a solution to any of life’s problems, including terminal illnesses.  The temptation to believe that alcohol and drugs are a solution is part of the delusional system that accompanies chemical addiction.

The Choices In Facing A Terminal Illness

When facing a terminal illness, we only have three choices.  We can deny it by pretending everything is fine.  We can fight it by learning all that we can about our disease, fortifying our sobriety, steeping ourselves in courage and hope, and doing everything we know how to do to increase the duration and quality of our survival time.  Or we can accept it.  We can face the inevitability of our death and surrender to it.  By surrendering we can reinvest our energy in finding a sense of dignity, and meaning in the experience of our illness and death.  We can finish our business here on earth and turn to strengthen ourselves spiritually to face the transition from this life to the next.

Which is the best or correct way?  There is none.  We each will have to choose which of these alternatives we will embrace at each stage of our movement toward death.  At times, it is best to deny our illness and live as if we will live forever.  At other times, it is best to steep ourselves for the battle and fight for our lives with everything we have.  At still other times, it is best to surrender to the inevitable and face our death for what it is, the final transition of our physical lives.

The bottom line, however, is this — none of these alternatives will be available to us if we choose to use alcohol and drugs to cope.  Our disease of chemical dependency will rob us of all choice and self control. It will make our pain worse and rip us away from ourselves, our God, and those who love us.  Alcohol and drugs can never be a solution to anything for a chemically dependent person.

Reasons To Stay Sober

When Malcolm asked me the question, “Why should I stay sober?” my response was very direct, “Because you owe it to yourself and those around you.  Because you are in recovery and you are able to face anything sober and this includes your own eventual death.”

For a moment I became philosophical. “We can all create precious moments in time,” I said as I leaned forward and looked him in the eyes. “We can, at times, transcend our fear and carve out moments of joy and wonder.” I looked away for a moment a realized how often I had failed to follow my own advice. Then I continued: “We can choose to laugh when we feel like crying. We can live fully, even in the face of death. This is just true for us all.”

My mind flashed words of Earnest Hemingway: ‘All true stories end in death.’ In other words, we are all dying in every moment that we level. We are all living in every moment we are dying. We can choose to embrace life and revel in it, or we can choose to embrace death and quake in horror, fear and despair. Many people have told me the most painful thing they faced when confronted with their own impending death was how many moments in their lives they had wasted.

Then my rational brain took charge and I began explaining to Malcolm that there are seven good reasons to stay sober even if you have a terminal illness.

1. There Is Always Hope:

Only God decides when we die.  In recovery, we learn that we are not God.  Although we will all eventually die, the timing of our death is never certain.  Many people with HIV will never develop AIDS.  Of those who have AIDS, some will have spontaneous remissions and others will live a long and meaningful life before eventually dying.  On top of that, there is always the hope of a major medical break through in treatment.  Perhaps a cure will be found!  Even if such a break through never comes, people are happier and healthier when they live with hope than when they live in despair.

2. Staying Sober Increases The Length And Quality Of Survival Time:

Staying sober, eating right, exercising moderately and managed stress (all of the components of good recovery program for chemical dependence) will increase the length and quality of survival time.

3. Staying Sober Allows Us Connection With A Higher Power:

It is only in sobriety that we can experience a deep connection with our Higher Power and contemplate with hope what lies beyond the limits of our physical existence.  This is the only true source of comfort when facing our own death.

4. Alcohol And Drug Use Escalates Disease Progression:

Alcohol and drug use inhibits the immune system and accelerates the development of AIDS.  Alcohol and drug use will also interfere with the effectiveness of many of the new medications and other treatments that slow down the progression of AIDS.

5. Staying Sober Gives Us The Possibility Of Death With Dignity:

By staying sober, we can approach our death with dignity and self-respect.  We can reflect upon the meaning of our lives, the loves we’ve shared, the experiences we have had, the things we have accomplished and contributed.  We can bring closure to our lives and our relationships.  We can search for and find a deeper meaning to our lives and to our death.

6. Relapse Adds Pain And Problems To An Already Bad Situation:

When a chemically dependent person returns to alcohol and drug use, there is a big price to pay.  Physically, the booze and drugs rip our bodies apart and make us more vulnerable to the progression of other illnesses and less responsive to treatment.  Psychologically our self-esteem suffers and we develop shame, guilt and anguish.  This emotional response accelerates our plunge into depression and eventual despair.  Socially we become isolated and unable to give or receive love.  We inadvertently hurt the people we love most and cut ourselves off from one of the few sources of true comfort, the loving embrace of other human beings.  Spiritually we become bankrupt and disconnected from the God of our understanding.  We lose conscious contact with our source of courage, strength, and hope.

7. It Is Better To Die Sober Than To Die Drunk:

I strongly believe that it is better to die sober than it is to die drunk.  Using alcohol and drugs is never a solution for anything.  Alcohol and drugs cut us off from our inner source of courage, strength, and hope.  Addiction destroys our self-esteem and self-respect.  And, on top of that, it will make whatever other disease we have worse.  In the long run, it will create more pain and misery.

The Difference Sobriety Can Make

Staying sober in the face of terminal illness can and does make a difference.  I had two friends in recovery who died of cancer. One of them gave up hope and used his terminal illness as an excuse to relapse. He spent several months bingeing on booze and drugs and wallowing in self-pity. His behavior deeply hurt all of us who loved and cared about him. Most importantly, he ultimately hurt himself.  He cut himself off from those he loved and alienated himself from his higher power and his inner source of courage, strength, and hope. He ultimately decided to take his own life. He left devastation and scars on all those who touched him and died in personal misery.

My other friend faced his death sober. As a result, all who were involved with him benefited from his courage, his willingness to work through the steps and stages of accepting his own death, making his own personal peace, and being prepared to surrender himself spiritually. This friend died in a hospital surrounded by family, friends, and AA associates. His death was not pleasant, but he was able to face it using the wisdom and courage he learned in his twelve step program and through his years of recovery. As a result, he died in peace with himself and with others.  He finished the unfinished business of his life and he left behind him a legacy of the power of recovery, courage and compassion.  He showed us all the true strength of sobriety when supported by an effective recovery program.  He gave courage and hope to all who were involved with him in his final days.

Any recovery program that is strong enough to help people to face their own death in a sober and dignified way is a powerful program indeed. I wish that everyone suffering any chronic disease can learn to tap into that power.  As counselors and therapists, we need to believe in the power of the recovery tools that we teach and realize that they can assist a person in living a high quality life for as long as possible. They can help people to face the reality of their eventual death while finding the courage to live – even when they know we are dying.

Counseling The Terminally Ill

Counselors who are working with chemically dependent patients who are terminally ill need to develop a firm belief that alcohol and drug use will only make the condition worse.  Most importantly, they need to clearly and forcefully communicate that conviction to their patients.  They need to recognize that it is never in the best interest of the chronically ill patient to relapse into alcohol and drug use.

They also need to know that the use of pain medication, as prescribed, to improve the quality of the life in the face of severe pain is no a relapse. Without proper management, which usually includes a properly supervised pain medication regimen, the pain can become so severe that it destroys any ability to have quality survive time.

Therapist also need to be able to redirect their counseling and therapy towards three primary goals. The first is to maximize the use of treatment interventions that can produce a cure of the fatal condition. This means encouraging the patient to fight back against the disease by using the most effective treatment methods available. The second is to maximize the quality of survival time so that the person can live to the fullest in the remaining years, months, days, or hours of life. This means helping people to consciously bring closure to unfinished business, explore his or her values, and spend time engaging in valued activities.  The third is to develop a sense of spiritual fulfillment, which can allow patients to face their death with dignity and self-respect.  This means working through the stages of denial, anger, bargaining, and depression. This can bring people to a deep spiritual acceptance of death.

It is difficult for counselors in a death-denying society to realize that there are vital counseling interventions that can be used with terminally ill patients.  It is important to help people work through the stages of accepting their illness while still maintaining a sense of hope and a proactive vision of the future.

Counseling the terminally ill patient who is in recovery is the most challenging and, at the same time, the most meaningful experience that I have ever had.  Working with these patients in learning how to realistically face their own death has helped me come to terms with my own mortality.

Redefining Relapse

When working with terminally ill patients who often experience chronic and incapacitating pain, we have to think carefully and realistically about how we define relapse.  One of the most difficult challenges in counseling terminally ill, chemically dependent patients is to help them make wise and prudent choices about the use of medically prescribed painkillers.

I am a strong believer in abstinence as a primary treatment goal. I also recognize, however, the need that many patients have to find relief from intractable pain.  I have been approached by many people and asked if I consider it a relapse when terminally ill patients use painkillers such as Demerol or morphine.  My answer is a strong and resounding “No!  It is not a relapse!”  These pain medications are necessary to allow some quality of life.

It is important to remember that the pain associated with many chronic diseases can be more incapacitating than the use of legally prescribed painkillers.  There is a big difference, however, between using prescribed drugs under careful medical supervision and self-medicating addictively.

Counselors and therapists can learn how to help their patients come to terms with their needs for medically prescribed pain medications.  Counselors can help patients in the severe intractable pain to accept that this is not a break in sobriety. They can work with responsible pain-management physicians to develop an effective pain management plan that allows the longest and highest quality of survival time.

Relapse Warning Signs For Terminally Ill Patients

There are a number of relapse warning signs that can help terminally ill, chemically dependent patients recognize that they are moving toward a chemical relapse and take corrective action.  These are:

1. The belief that returning to the addictive use of alcohol and other drugs will make the illness more manageable or provide relief from pain.  As we discussed, the use of alcohol and other drugs will only make the disease worse.

2. The belief that the use of previous drugs of abuse will be more effective in pain management than the use of prescription drugs.  Most people quit using their drug of choice because they no longer get the desired effect.  This is the result of tolerance.  Your drugs of choice didn’t work well before and they won’t work well now.  Find a physician who will work with you in finding an effective medical regimen for the management of pain and supplement the medication with other forms of pain control.  This will be more effective in the long run.

3. The belief that returning to alcohol and drug use will bring about a quick and painless death.  Many terminal ill patients want to end the pain and mistakenly believe that alcohol and drug use will be an efficient way to commit suicide.  This is not true.  Death from chemical addiction is a slow and painful process both physically and psychologically.  If a person has decided to end his or her own life, there are other more effective and painless ways to commit suicide.

4. The belief that having a terminal illness means that there is nothing left to live for and, therefore, alcohol and drug use is justified.

When I finished, Malcolm stood up, put on his hat and said: “Thank you, I have a lot to think about.” As I shook his hand and turned to walk away, I realized that, like Malcolm, I also had a lot to link about.


DRAMA and CATHARSIS

October 15, 2013

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Drama as a formal public experience began in ancient Greece. It was observed that those witnessing a well acted drama, especially an intense tragedy, got caught up in the experience and felt better afterward. This may well have been the first form of cathartic therapy.


EMPATHY SKILLS AND RELATIONSHIPS

October 14, 2013

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EMPATHY is the ability to notice, sense, and understand the experiences of others. Empathy can be understood as consisting of a number steps, each related to a skill that can be learned.

1. Empathy begins with the ability to center yourself and notice what you are thinking and feeling in the moment. We tend to assume that others are thinking and feeling the way we are. It is difficult to understand that the other person may have very different thoughts and feelings than we have. It is important to step out of our own mind-set and feelings in order to communicate on a deeper and more meaningful level with others.

2. Understanding the shared social and cultural context that gives the situation meaning. It is common for people in familiar situations to take the social context for granted and forget that it could be influencing the experience of others. In other words, I may experience the context as one inviting intimate communication. The person I am with may feel that the context is inhibiting to deeper intimate communication.

3. What beliefs about yourself, the other person, and the world are you bringing into the situation. These beliefs shape what you expect to see and whether you see the other as normal or abnormal as measured by your expectations. You are bringing beliefs into the situation that can be projected onto the other person. What you are projecting upon the other person may or may not fit who the person really is.

4. To what degree can you step out of your own experience and mindset and just notice the other person –just be aware of the other person’ point of view.

5. How skilled are you at expressing to the other person, both verbally and non-verbally your genuine responses to who they are and what they are doing. Genuine expressions can be both emotionally and understood intellectual.

The level of empathy increases as you become better at being accurately aware of the here-and-now experiences of others, being aware and showing your own here-and-now experiences to others, and communicating clearly and without pre-judgment about how you are experiencing the other person.

Empathy can both make us more vulnerable because we show others who we are in both our strengths and our weaknesses. Intimacy can also make us seem more threatening because the person we are talking with feels that their strengths and weaknesses are visible to you.

The level of Intimacy us the ability to share close honest human experiences with others. It is directly related to the levels of shared intimacy.

The level of genuine trust requires high levels of shared intimacy. As a result, intimacy skills are central to building and maintaining close and trusting relationships.

Gorski Books: www.relapse.orgl


ADDICTION IS A BIOPSYCHOSOCIAL DISEASE

October 14, 2013

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This is true for all chronic lifestyle-related illness. It is hard to keep this dynamic concept of biopsychosocial processes in mind. We are so used to seeing these three levels (biological, psychological, and social) as distinctly separate things rather than dynamically interacting processes that it us difficult to keep the continuous dynamic interactions in mind.

In addiction, the reward system of the brain distorts the biological basis of thinking and feeling. The mind reacts psychologically by developing an addictive belief system and self-reinforcing denial systems. These addictive psychological systems cause changes behavior which in turn effects relationships and social consequences. As relationships change, behavior adapts to accommodate changing relationship dynamics. The personality slowly adjusts to accommodate the new emerging social reactions.

The brain is plastic. This means that the brain grows and changes in response to thoughts and behavior. The brain adapts in ways that reinforce the entire addictive process.

The addictive drugs and behaviors become central to “normal” functioning of the brain, mind, and social system.
This entire self-reinforcing process is like a wave passing rapidly from brain to mind to social consequence and back again – but nearly at the speed if light.

It is much easier to think of three concrete things: the addictive brain, the addictive mind, and addictive social/cultural systems. It is important, however, to keep the dynamic interaction of these three levels of being in mind. All three need to be included in comprehensive treatment.

These three levels must be addressed concurrently, not sequentially. All stages of recovery contain physical, psychological, and social recovery tasks. All three approaches need to be integrated in individually designed programs if treatment.


Peaceful – Even For A Moment

May 27, 2012

ImageI want to be peaceful, if only for a moment;
to turn off the pain for a little while;
to stop the ever-present chattering of my mind.

These are the things that most addicts want. The only thing they know that will give it to them is their drug if choice. At first it works well, right whenever the addict uses it.  Then, like a fickle friend, the drug of choice plays the ultimate trick.

The addict needs to use more and more to find that moment of peace! It takes less and less to release the monster of intoxication. All too soon the drug of choice stops working and starts destroying. It becomes a problem instead of a problem solver. It causes pain instead of taking it away. It creates inner turmoil and destroys any chance of finding the peaceful state that it originally promised. The big lie of alcohol and drugs becomes clear – they will not permanently peacefulness to the troubled mind. They will not take away my pain or solve my problems.

My drug of choice no longer gives me what I want, but the pain and emptiness of stopping seems unbearable. I am addicted. Trapped by that which once set me free. This is the reality of addiction. It is a game for losers who want to believe in the quick fix and the easy way out. It’s easy to start and difficult to stop. Admission is free but addiction makes you pay a big price to get out.



The Mind Is A Powerful Thing

May 13, 2012

The mind is a powerful thing. It grows and changes in response to our experiences and willful choices. The concept is known as brain plasiticity. The brain grows and changes in response to our experiences throughout the entire human life cycle.

As a result of brain plasticity, the mind – within a set of limits not yet known – can heal the body . We push those limits by focusing our conscious thoughts upon setting goals, developing plans, and working hard to actualize those goals. We do it by thinking, imaging, and creating a vivid and compelling vision of what we want to become. By this imaging or vivid re-imaging process, we expand the capacity of our mind-brain and actually rewrite our programing and our potential. This is how we actualize our dreams. To actualize means to make real through action. 

The brain is the physical foundation of the mind. The mind is the non-physical aspect of human consciousness that makes us self-aware or self-conscious. This self-awareness makes us capable of not only knowing who and what we are, but knowing that we know. Self-awareness gives us the capacity to grow beyond the limitations of genetic programing.

This capacity for self-awareness is called the higher self, or the observing self, or the silent witness. This capacity to detach, observe ourselves, and make decisions to change gives us the capacity to grow beyond our previous programing and our previous limitations. It does not happen on its own. We must make the choice and take the steps to make it happen.

The way we anticipate what tomorrow may bring, sets the power of our mind-brain to work. Tomorrow always comes, bringing with it both new promise and new challenges. The way we practice anticipating tomorrow trains the brain to respond as if it were so. In this way, we condition the brain to create, again within limits unknown, the tomorrow we anticipate and mentally prepare for, rather than the tomorrow we desire.

There is always something to be grateful for. gratitude focuses the mind on the positive experiences of the past, and by doing so, trains the mind in the present, to reproduce the object of gratitude in the future.

A Gratitude List, therefore,  Is a powerful tool for focusing the mind on what really counts. As we focus our mind, the brain will slowly follow. As the brain follows, the body heals. Like a boat well made, the mind and body are self-righting mechanisms designed to stay afloat during storms, and even if turn over, to right themselves. The ability rebalance is built into the design. This is why I believe that the mind is a powerful thing! 

Read: Straight Talk About Addiction
by Terence T. (Terry) Gorski
http://www.relapse.org – www.cenaps.com


Chemical and Process Addictions

May 4, 2012

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By Terence. T. Gorski

Addictions can be organized around different triggers that activate the Core Addiction Syndrome. These activating triggers have one  thing in common – they activate an addictive brain response. This means that the brain is flooded the brain with pleasure chemicals that create a unique sense of euphoria while being inhibiting from producing warning chemicals which cause the feelings of stress, anxiety, fear, and panic.: As a result when people expose themselves to addictive triggers, their brain responds with an addictive brain response which positively reinforces them to keep hitting the addictive trigger. When people stop hitting the addictive trigger they experience dysphoria,  The triggers for the addictive brain response can be classified into two major groups:

  • Chemical Addictions to mind/brain altering substances (which include alcohol, illegal/illicit drugs, prescription medications, and over-the-counter medication)
  • Process Addictions to mind/brain altering behaviors (which includes food, sex, gambling, work, and money).

A large number of people switch from one addiction to another. This often goes unnoticed because of problems with language. Most people, even most professionals, think only of chemical addictions when they hear or read the word addiction. Many people describe process addictions as compulsions or else describe them in the context of DSM using words like sexual disorders, eating disorders, etc. The idea of a process addiction doesn’t even come into mind.

Most people have an addiction of choice. In other words, they receive treatment for a chemical addiction, and then in sobriety, they crossover or migrate to another addiction, often a process addiction. The negative consequences of the process addiction causes pain and problems in “sobriety” that can lead back to the use mind/brain altering chemicals. This progression of pain and problems in sobriety are often called Early Relapse Warning Signs.

The switching of addiction –from chemical to process and then back to chemical –is a common but not universal phenomena. This raises the questions of whether chemical dependent people with a process addiction have independent and co-existing disorders, or if there is an underlying core addiction syndrome that drives them both. This is, of course, black-and-white thinking, which is not always helpful. Perhaps chemical addictions and process addiction share some things in common yet have significant difference.  This is a reasonable position, especially in light of a long history in the addiction field of defining different types of addiction.

In the next blog we will look at the simalarities between chemical and process addictions.

Terence T. (Terry) Gorski

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