Relapse Prevention Therapy (RPT) – An Affordable Evidence-based Practice

November 8, 2014

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By Terence T. Gorski, Author

 

Relapse Prevention Therapy (RPT) is an Evidence-based practiced that is recognized by both the National Registry of Evidence-based Programs and Practices (NREPP) and the National Institute of Drug Abuse. This is important because relapse following drug treatment is quite common and a collection of tools have been forged into a system for both preventing relapse and stopping it quickly should it occur. “RPT is a behavioral self-control program that teaches individuals how to anticipate and cope with the potential for relapse” (NREPP). In addition, RPT serves to normalize relapse as part of the overall recovery process, thus reducing the negative feelings and behaviors that result from a setback. RPT also provided relapse tools and techniques that patients learn early in treatment that can stop relapse quickly should it occur.

The GORSKI-CENAPS Model of RPT brings proven evidence-based practices to recovery and relapse prevention by providing effective and easy to use methods for identifying and managing early relapse warning signs and high risk situations. It also presents methods for planning to stop relapse quickly should it occur. All of the key practices of evidenced-based Relapse Prevention Therapy (RPT) are made available in practical and easy to use workbooks. Training is available to teach the most effective ways to make use the workbooks in individual and group therapy and in support groups. There is also an internationally registry of Certified Relapse Prevention Specialists (CRPS) that are trained to support RPT program implementation.

The Research Supporting RPT Effectiveness

Prevention (RP) is an evidence-based intervention. There is compelling evidence in the literature documenting its effectiveness.

First, let’s look at the results of a meta-analysis of 26 published and unpublished studies with 70 hypothesis tests representing a sample of 9,504 participants. (Irvin et al, 1999)

  • Relapse Prevention (RP) was found to be a widely adopted cognitive-behavioral treatment (CBT) for alcohol, smoking, and other substance use.
  • RP was generally effective, particularly for alcohol problems.
  • RP was most effective with alcohol or polysubstance use disorders combined with the adjunctive use of medication

Validation of Gorski’s Relapse Warning Signs

Though it has enjoyed widespread popularity, Gorski’s post-acute withdrawal syndrome (PAWS) model of relapse has been subjected to little scientific scrutiny. A scale to operationalize Gorski’s 37 warning signs was developed and tested in a larger prospective study of predictors of relapse. Of central interest were: (1) whether the warning signs hypothesized by Gorski are interrelated in a meaningful single factor and (2) whether the hypothesized syndrome would accurately predict subsequent relapses.

A sample of 122 individuals (84 men) entering treatment for alcohol problems was followed at 2-month intervals for 1 year. The Assessment of Warning-signs of Relapse (AWARE) scale was administered at each assessment point, and the occurrence of both slips (any drinking) and relapses (heavy drinking) was monitored during each subsequent 2-month interval. Principal factor analysis was used to study the factor structure of the warning signs.

The results showed that: (1) Of the 37 warning signs, 28 clustered as a robust single factor with excellent internal consistency (Cronbach’s alpha: 0.92-0.93); (2) A conservative evaluation of test-retest stability across 2-month intervals estimated reliability at r = 0.80. (3) After covarying for prior drinking status, clients’ AWARE scores significantly predicted subsequent slips and relapses. Relapse rates for clients with highest AWARE scores, as projected by regression equations, were 33 to 46 percentage points higher than those for clients with lowest AWARE scores, after taking into account prior drinking status.

The conclusion is that this scale of Gorski’s warning signs appears to be a reliable and valid predictor of alcohol relapses. (J. Stud. Alcohol 61: 759-765, 2000)

Relapse Prevention (RP): Controlled Clinical Trials (Carroll 1996)

(1) More than 24 randomized controlled trials have evaluated the effectiveness of cognitive-behavioral relapse prevention treatment on substance use outcomes among adult smokers, alcohol, cocaine, marijuana, and other types of substance abusers. Review of this body of literature suggests that, across substances of abuse but most strongly for smoking cessation,

(2) There is evidence for the effectiveness of relapse prevention compared with no-treatment controls across all drug categories.

(3) Relapse Prevention is most effective at:

  • Treating patients with long histories of chronic relapse after attempting recovery with other treatment methods.
  • Maintaining the positive effects of improvements made during treatment (enhanced durability of effects)
  • Reducing the length and severity of damage caused by relapse episodes when they occur;

(4)      The positive effects of RP are enhanced by patient-treatment matching.

(5) Patient-treatment matching improves outcomes for patients at higher levels of impairment along dimensions such as psychopathology or dependence severity.

Manualized Treatment

Manualized Treatment Improves Effectiveness of treatment (i.e. increases recovery rates, decreases relapse rates, and produces shorter less destructive relapse episodes. The results are achieved while reducing time in therapy.

The primary treatment manuals that help produce these outcomes are:

  1. Starting Recovery With Relapse Prevention Workbook: A workbook designed to integrate basic relapse prevention principles in to the first attempts at addiction recovery.
  2. Cognitive Restructuring for Addiction Workbook: A workbook designed to teach and apply the basic recovery skills of thought management, feeling management, behavior management, impulse control, the use of mental imagery, and a serious of relaxation methods, including mindfulness meditation, that has been proven to enhance the effectiveness of the cognitive component of relapse prevention. This work allows an easy application of RPT methods to a wide variety of additive and mental health problems.
  3. Relapse Prevention Counseling (RPC) Workbook: This is a guide for understanding and managing craving and high risk situations to avoid relapse during the critical first ninety days of recovery.
  4. Relapse Prevention Therapy (RPT) Workbook: This is a guide for helping recovering people with a stable recovery program to identify and manage the personality and lifestyle problems that can so must pain and dysfunction in recovery that self-medication seems like a positive choice. This workbook takes RPT to a deep psychotherapy level.
  5. Problem Solving Group Therapy (PSGT): There are two simple guidelines for using RPT in problem solving groups. There is a Participant Guide to prepare group members with easy to understand information on how to succeed at group therapy and a group leader guide giving in-depth instruction how to start, conduct, and manage common problems that occur in problem solving groups.

When these five practical tools are brought together into a well designed and comprehensive treatment program the quality of care, moral of the staff, and positive long-term outcomes of treatment tend to improve.

WORKBOOKS  USING RELAPSE PREVENTION THERAPY (RPT) – AN EVIDENCE-BASED PRACTICE  http://wp.me/p11fHz-7s

References

The CENAPS Model of Relapse Prevention was originally developed by Terence T. Gorski and continually updated to integrate new research findings. (Gorski 1990, )

Carroll, Kathleen M., Relapse prevention as a psychosocial treatment: A review of controlled clinical trials. Experimental and Clinical Psychopharmacology, Vol 4(1), Feb 1996, 46-54.

Gorski, Terence T., The CENAPS Model of Relapse Prevention: Basic Principles and Procedures, Journal of Psychoactive Drugs, Vol. 22, Issue 2, 1990, pages 125- 133, ON THE INTERNET: http://www.tandfonline.com/doi/abs/10.1080/02791072.1990.10472538

Irvin, Jennifer E.; Bowers, Clint A.; Dunn, Michael E.; Wang, Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology, Vol 67(4), Aug 1999, 563-570.

Miller, William R. and Harris, Richard J.  A Simple Scale of Gorski’s Warning Signs for Relapse, Journal of Studies on Alcohol and Drugs, Volume 61, 2000, Issue 5: September 2000 ON THE INTERNET: http://www.jsad.com/jsad/article/A_Simple_Scale_of_Gorskis_Warning_Signs_for_Relapse/814.html

 

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CERTIFIED RELAPSE PREVENTION SPECIALISTS (CRPS)

September 2, 2014

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An Evidence-based Program and Practice

By Terence T. Gorski, author,

Find A CRPS Near You

Find a CRPS providing services in your area. Click Here. Most provide a minim of thee services on a fee for service bases:

1. RP Counseling and Therapy:

Direct RP services for recovering people and their families in developing and supervising relapse prevention plans. Some do this in individual sessions and others in groups.

2. Clinical Supervision/Case Consultation:

Clinical supervision in RP for professionals in the community working with relapse prone people. Again, some do this in individual supervision and some use group supervision.

3. Training and Presentations On Relapse Prevention and Related Area:

Many of our Professionals who have earned their CRPS do. Wide variety of training events for professionals and recovering people in the community.

I have found the members of the Association of Relapse Prevention Specialists to be dedicated and competent professionals with big hearts. They are just plain good and trustworthy people.

You can locate a certified Relapse Prevention Specialist near you by visiting the CENAPS Website: Certified Relapse Prevention Specialists (CRPS)

 

Supervision.http://www.cenaps.com/The_Cenaps_Corporation/Certified_Specialists.html Supervision.

The Relapse Prevention Certification school id conducted ever November in Fort Lauderdale FL
BECOME A CERTIFIED RELAPSE PREVENTION SPECIALIST (CRPS):

 

 


Complexity: The Comprehensive Bio-Psycho-Social-Spiritual-Cultural-Economic-Political Profile

September 1, 2014

thBy Terence T. Gorski, Author
President, The CENAPS Corporation

Gorski’s Book, Straight Talk About Addiction,
further explains the implications of the distinction between
the brain and the mind in addiction recovery.

Please view this blog as a work in a progress. See it as a passing glance through a partially opened window of my brain/mind, Forgive me, for the room you are glancing into is still cluttered and poorly organized, yet you will see some interesting things emerge from  this superficial examination of the clutter.  As I said, I have not yet fully explored and organized these ideas. I started this blog with a simple idea and became possessed by something newer and for more complex.
I started to write a simple blog asserting that I believe we have both a physical brain and a nonphysical mind and that both are equally important. I wanted to lash out at the flat-landers who would smash human experience into the single dimension of nerve cells  firing as they rub up against each other and band into the environment. My argument was going to be simple: the brain is an important thing, but it is not the only thing.

The paradigm of the BRAIN-MIND is emerging to explain how the physical brain, connects with and is sensitive to the nonphysical actions of the mind. THE BRAIN is the physical structure that supports the nonphysical actions of the THE MIND. We, as human being, are sentient beings with a neuroplastic brain is capable of reprogramming itself based upon experience throughout the entire human life span.The ability to self-regulate the brain-mind assigns meaning to life experiences which can become culturally based beliefs that cause the development complex shared beliefs and personalities that influences our behavior, relationships, and social structures. This can lead to stress, conflict, violence, pain, trauma, stress-related illness, , addiction, and mental health problems. The Brain-Mind takes note and moves to correct the problems.

Medicines can certainly save lives and ease suffering, but so can our interactions with other people who care about us and have well-developed helping characteristics.  The environment in which we live has a lot to do with health and illness. It is incredibly important in terms of alcoholism and drug abuse. Certain kinds of neighborhoods become the incubators of drugs dealers, crime, and violence. Where we live, who we live with, and the nature of our relationship with those we live with has a lot to do with getting addicted, getting clean and sober, staying clean and sober, or relapsing. All these things have a lot do with addition, mental health, and lifestyle-related chronic illness.
As I thought about it, the environment also has a lot to do with illness injury and accident. Some of the greatest improvement in public health did not come from medicine, that came from improved sanitation, safer cars, and the awareness of and elimination of toxic substances in our homes and workplaces. Medicine, of course, base a place in the treatment of heart disease, but so does nutritional science, stress management, and motivational counseling to keep people going with the big changes demanded of heart-healthy living. The lifestyle and stress-related illnesses are among the most difficulty  to treating and the most relapse-prone..
Chronic Life-style-related Illness
Is the Most Difficult To Treat
And the Most Relapse Prone.
In my opinion, the future direction for improving our ability to treat chronic addiction and other lifestyle-related illness will not come from a revolutionary new treatment for these lifestyle-related problems. I would celebrate if that were to happen, I just don’t believe that it will. The next big breakthrough that I see coming in the treatment of addiction and other lifestyle-related illness will not be revolutionary. It will be evolutionary and it is slowly unfolding before out eyes right now.
Brain-Mind Cascade

The Brain-Mind Cascade

There are evolutionary changes pushing us inevitably toward conquering addiction and other lifestyle-related diseases. The evolution involves examining everything we have ever done that helped out clients. It also involves bring all these success stories, no matter how small, together. We view each little success story as a piece in the puzzle to a complicated life-long chronic disease management process.    Then we put them into a big pile (the big pile is actually a high power computer) and start looking for similarities and complimentary components. (The computer actually does most of the looking. We push a button and let the computer do the hard number crunching in the cyber-space world of correlations and algorithms.)

This will allow us to dramatically increase the amount of data that get analyzed and integrated our current knowledge-base of addictive, mental, and stress-related  illness.  This future direction that I believe holds the most promise. We integrate what we already know and look for new combinations and insights. We do this by  organizing the mountain of data into a new grid. I believe that if we could pull off this comprehensive BIOPSYCHOSOCIAL AND ENVIRONMENTAL synthesis of what we have already know, we will be able to find ways of matching patients to treatments and to prevention strategies that could reduce stress-related and life-style related illness by up to 75% in ten years.  It is possible, but it would take a major effort. The necessary funding would require financial reorganization that would probably fail to gain any political traction.
We would need to bring together everything we have learned that helps people to recover across all areas of study. This would mean mapping out a … well a …  Heck, there is no name for the type of map we would be creating. It would be as big a deal as mapping out the human genome, but at least the genome has a name. I can’t think of a good name for dynamic ever-growing map of the human condition so I will call it a comprehensive human bio-psycho-social-spiritual-cultural-ecnomic-political profile. (This name sounds simple and easy to remember, does it not?)
This task is as challenging, perhaps more challenging than mapping the human genome. It would involve getting dozens of different professionals, working in different areas of speciality expertise, who operate in different profession cultures, who use different specialty language, who compete for the same funds, and who usually dislike communicating  across the professional and specialty lines because they don’t really respect what the other professionals are doing. We need to get several million of these professionals to become committed to a collaboration that could change on multiple levels the health of billions of people and the planet they live on.
This collaboration could change on multiple levels
the health of billions of people and the planet they live on.
All specialties would be important. Collaboration and the willing to learn across disciplines would be the cultural organizing theme.  Since each speciality tends to have it own unique professional jargon, it would mean creating a new common-sense language tha could be understood across disciplines and by the common folk who suffer from the illnesses being studied.. It would involve many cross-walks between different ways of thinking: people doing pure science would have t cross-walk their ideas with people doing clinical work.
The people suffering from the human condition, which is nearly every human being alive at some pint in his or her life, needs to be invited to participate. They would be invited to log  onto smart social networking bulletin boards. These smart bulletin boards will allow people to tell the story of their disease and recovery, to describe their symptoms and related issues, and to report what they found helpful, not helpful, and harmful. There would be social networks linking people together to exchange information.
This would require big computer power — and we have that already. It needs to be designed for easy use by ordinary people who can easily enter their experiences with their disease or conditions. This probably means both key-board and voice-activated input — and we have those already.  The computer will organize the information into a big number analysis. The most difficult part of the model is that a wide variety of social, cultural, spiritual, religious, and political factors which affect the health or illness generating capacity of the environment must be included.
The next big breakthrough in the treatment of
addiction and other lifestyle-related illness
will not be revolutionary. It will be evolutionary and
its is slowly unfolding before our eyes right now.
It it were possible to build  this comprehensive multidimensional map of human existence, interesting links and new approaches to cross-disciplinary treatment would begin to emerge.  The technology s here right now. I am sure I am not the only on generating this idea or some variation, so the idea is coming of age.  The financial resources are there, but would need to be redirected which would force a cultural change in values. So what s missing? The only missing element is an army of willing of professionals who are wiling ton take up the challenge. People don’t like change and most people don;t like to take risks. The fear of launching into a new comprehensive paradigm of total  a comprehensive human bio-psycho-social-spiritual-cultural-ecnomic-political profile could open up a whole new environment paradigm and a new way of doing medicine.
This vision is emerging from studying the trends presented by Jeremy Rifkin in his books The end of Work, The Third Industrial Revolution, and the Zero Marginal Cost Society. tThe world is well into the information age that allows us to do things that seemed impossible just two decades ago.  
It is interesting to see the emerging correlations between brain function and such diverse areas as behavior, stress, personality, addiction, violence, interpersonal communication, individual and collective problem solving, and mental health disorders. Looking at these relationships  raise a very old question: does the physical brain or the non-physical mind determine our ability to control our behavior or does behavioral control result from the proper use of the non-physical mind?
There is another factor pushing the process in the information age. Health care is becoming patient driven as the internet provides readily available and scientifically valid descriptions of symptoms, illnesses, medications, and other treatment modalities. The mutual support groups starting with 12-Step programs are expanding through the internet to include high level patient collaboration and even patient initiated studies. Relatively inexpensive websites with smart bulletin boards organizes and sort information into categories to give a bigger picture that could have ever been seen before.

The answer, of course, is yes! At different times the survival responses of the brain (fight, flight, freeze) plus our deeply conditioned habits take over control and we do things we either are not aware of that, in spite of our awareness, we would prefer not to do. (Have you ever had your mouth take on a life of its own during an argument?). At other times we make conscious rational choices governed by the lifestyle we live and the people places and things we choose to associate with.

Today we are coming to the end of a failed paradigm that the physical brain is all that there is. All of the accomplishments and tragedies of mankind ia causes  by a clump of cells that accidentally at some point became self-aware.  Everything is pointing to a non-physical mind that inhabits and works with the physical brain to allow human beings to survive, thrive, maintain health, manage illness and keep moving forward with courage in to an uncertain future.

 

 


Poison As A Preferred Pleasure 

August 16, 2014

969274_625783080787533_1366431777_nBy Terence T. Gorski, Author

I am constantly amazed by how many people view alcohol and marihuana as harmless. Even more frightening is the willingness of people of all ages to put unknown substances into their bodies that are produced by criminals who give the promise of getting high.

All psychoactive chemicals change mood by directly changing how the brain works. Small doses of brain-altering chemicals can cause serious problems with the ability to think clearly, manage feelings and emotions, remember things, use good judgment and control destructive impulses.

The brain can recovery most of the time, but not all if the time. In the best of circumstances the recovery of the brain usually happens slowly.

I suggest it is good idea to be very careful about the things we put into our bodies that can damage the brain. In make this suggestion with the same level of seriousness that I suggest you always wear a parachute when you jump out of an airplane.

“I have never used any mind altering drug that was not pharmaceutical grade. People who put drugs of unknown composition and purity in their bodies are either ignorant (they don’t know the real risks to the brain and mind), stupid (they know the risk and choose to ignore it), or addicted (they know the risk, want to stop, but find that they can’t). ~ Timothy Leary, in a private conversation with Terence T. Gorski


Addiction Can Be Understood and Treated

August 15, 2014

RECOVERY IS POSSIBLE
STRAIGHT TALK ABOUT ADDICTION

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Straight talk means giving clear, honest, and plain-English descriptions of important issues related to addiction, recovery, relapse prevention. Straight Talk means discussion the artistes for addiction — sobriety and responsible living.

This book tells it like it is without a great deal of concern for political correctness or the tentative guarded language that so often hides the truth about addiction, recovery, and relapse.

After 40 years of following the new research and treatment practices for addiction, Terry Gorski became frustrated at the misinformation about alcohol and other drug addictions and the narrow and incomplete approaches to treatment, recovery and relapse prevention.

In this book, Terry provides the best information on the current science-based upon an accurate understanding of what the core addiction syndrome is and what the an effective addiction treatment process needs to look like if it is to increase the chances of recovery and decrease the risk of relapse.

This book is easy to read and loaded with useful information. The book can be quickly read from beginning to end, and then kept as a handy reference to find specific information that can be used as a guide to manage the problems and crises that are so often a part of the addiction and recovery process.

The message is simple: addiction is a biopsychosocial disease. science-based understanding of what the core addiction syndrome is and what the core addiction treatment process needs to look like if it is to increase the chances of recovery and decrease the risk. Here are some of the key ideas developed in depth with the book:

Addiction is a biopsychosocial disease. Bio means biological or of the body, Psycho means psychological or of the mind, Social means the relationships that develop among people and with the social and legal systems that are needed for responsible living.

Biologically, addiction is marked by brain dysfunction that disrupts the reward chemistry of the brain creating cycles of intense euphoria and powerful craving.

Psychologically addicted people slowly adjust their ways of thinking, feeling, acting that allows them to deny and rationalize the problems caused by the it addiction.

Gradually, over time, an addictive beliefs develops that create a powerful denial system. This denial blocks the ability to recognize the addiction, interferes with the ability to ask for and accept help, and creates a deadly spiral of progressively more severe relapse episodes.

Socially, addiction pushes away sober and responsible people while attracting and feeling attracted to addicted and irresponsible people. The result is a tragedy. The addict abuses, disregards, and destroys those who love and try to help them. Active addicts set themselves up to be exploited by other addicted people and are vulnerable to predators who use and abuse them.

Most importantly Straight Talk About Addiction provides hope. Addiction and be understood, recovery is possible, and relapse can be prevented it effectively managed should it occur.

This book is easy to read and understand. It is loaded with useful information. Many people read it from beginning to end to get a comprehensive understanding of addiction, recovery, relapse, and related problems. Many people keep the book handy so they can use it as an easy-access reference to find useful information that can be used to effectively manage addiction-related problems.

The message is clear: Recovery is possible. Relapse can be prevented or effectively managed should it occur. There is hope.

LIVE SOBER – BE RESPONSIBLE – LIVE FREE

Get The Book By Terence T. Gorski
STRAIGHT TALK ABOUT ADDICTION


Using Stress Management In Relapse Prevention Therapy (RPT)

August 3, 2014

thBy Terence T. Gorski, Author

This blog is an excerpt from the book:

Starting Recovery With Relapse Prevention
by Terence T. Gorski. 

GORSKI’S RELAPSE PREVENTION CERTIFICATION SCHOOL (RPCS)
November 10 -14, 2014 at the Hyatt Regency Pier Sixty Six

2301 SE 17th Street Causeway, Fort Lauderdale, FL 3331
Iinformation: Tresa Watson: 352-596-8000, tresa@cenaps.com
Course Description: www.cenaps.com

Stress management is a critical key to staying away from alcohol and other drugs[i] [ii]during the critical first two weeks of recovery.[iii] It is important for people in recovery to learn how to recognize their stress levels and use immediate relaxation techniques to lower their stress. [iv] [v]

Recovering people are especially vulnerable to stress.[vi] There is a growing body of evidence that many addicted people have brain chemistry imbalances that make it difficult for them to manage stress in early recovery. The regular and heavy use of alcohol and other drugs can cause toxic effects on the brain that create symptoms that cause additional stress and interfere with effective stress management.

SEE RELATED BLOGS:
Stress Self-Monitoring and Relapse ,
The CENAPS Model and Mindfulness in Relapse Prevention,  and
Mindfulness Made Simple.

Many people who are in recovery from addiction have serious problems with Post Acute Withdrawal (PAW). PAW is a bio-psychosocial syndrome that results from the combination of brain dysfunction caused by addictive alcohol or drug use, and the stress of coping with life without drugs or alcohol. PAW is caused by brain chemistry imbalances that are related to addiction. PAW disrupts the ability to think clearly, manage feelings and emotions, manage stress, and self-regulate behavior.

PAW is stress sensitive. Getting into recovery causes a great deal of stress. Many recovering people never learn to manage stress without using alcohol or other drugs. Stress makes the brain dysfunction in early recovery get worse. As the level of stress goes up, the severity of PAW symptoms increase. As PAW symptoms get worse, recovering people start losing their ability to effectively manage their stress. As a result, they are locked into constant states of high stress that cause them to go between emotional numbness and emotional overreaction. Since high stress is linked to getting relief by self-medicating stress with alcohol or other drugs, high stress gets linked with the craving for alcohol or other drugs. So one of the first steps in managing craving is to learn how to relax and lower stress without using alcohol or other drugs.

The severity of PAW depends upon two things: the severity of brain dysfunction caused by addiction and the amount of stress experienced in recovery. The first two weeks of recovery is the period of highest stress in recovery. This high stress occurs before you have a chance to learn how to manage it in a sober and responsible way. Since you cannot remove yourself from all stressful situations, you need to prepare yourself to handle them when they occur. It is not the situation that causes stress; it is your reaction to the situation.

According to the National Institute on Drug Abuse, exposure to stress is one of the most powerful triggers for relapse to substance abuse in addicted persons, even after long periods of abstinence. Stress can cause a problem drinker to drink more, a person using prescription medication to use more than prescribed, and an illicit drug user to get more deeply involved in the drug culture than they could ever imagine. The high stress of the first two weeks of recovery can activate powerful cravings that make people want to start self-medicating with alcohol or other drugs in spite of their commitment to stop and stay stopped.

There is a simple tool called The Stress Thermometer that can help you to learn how monitor your stress. There is a simple immediate relaxation technique called Relaxed Breathing that can help you noticeably lower you stress in two to three minutes. First, let’s talk about the Stress Thermometer.

The Stress Thermometer

The Stress Thermometer is a self-monitoring tool that teaches people to become aware of their current stress levels, notice increases and decreases in stress at different times, and encourages the use of immediate relaxation techniques to lower stress as soon stress levels begin to rise. The Stress Thermometer makes it possible to manage stress before craving for alcohol or other drugs is activated. Lowering stress can also lower cravings. Lowering cravings can help you to turn off denial and addictive thinking. (More about this later).

The concept of using a stress thermometer came from thinking about how we use a temperature thermometer to measure our body temperature. When we take our body temperature we use a thermometer to tell us accurately and objectively what our body temperature is. When we use a stress thermometer, we use a system for self-monitoring our stress levels that can tell us accurately and objectively how high our stress levels are.

The stress thermometer is divided into four color-coded regions: blue – relaxation, green – functional, yellow – acute stress reaction, and red – trauma reaction.

What the Stress Levels Mean

Low Stress/Relaxation: Stress levels 1, 2, and 3. These stress levels are coded blue because they are cool and relaxing.

  • Stress Level 1: Deeply Relaxed/Nearly Asleep: At Stress Level 1 you are in a state of deep relaxation and nearly asleep. Your mind is not focused on anything in particular and you feel like you are waking up in the morning to a day off and can just let your mind drift in the deeply relaxed state.
  • Stress Level 2: Deeply Relaxed/Not Focused: As you come back from a state of deep relaxation you enter Level 2, during which you stay very relaxed, but begin to notice where you’re at, what is going on around you. You can stay in that state and just be aware and deeply relaxed. Eventually we will either go back down to Level 1 and then perhaps falls asleep or else you will move up to Stress Level 3.
  • Stress Level 3: Deeply Relaxed/Focused:At stress level 3 you get focused and start to think about getting yourself back into gear and getting going. In other words, you are getting ready to “kick-start your brain” so you can move into a functional stress level to begin getting things done.

By practicing the Relaxed Breathing Technique (this will be explained on page 19) most people can learn to put themselves in a relaxed state (Stress Level 1, 2, or 3), stay there for a few minutes, and then come back feeling refreshed and relaxed. It is important to remember that this will take time and practice. In our culture people are taught to work hard and burn themselves out. People don’t get much training on how to relax. People who get a euphoric effect from using alcohol or other drugs don’t need to. When they get the “right amount” in their system they shut down their stress chemistry, turn on the pleasure chemistry, and feel relaxed.

It is important to practice relaxation four times per day. I recommend linking it to meals: Take five minutes in the morning before breakfast, five minutes at lunch, five minutes at dinner, and five minutes to relax before going to sleep. Taking these stress breaks will make it easier for you to stay at a functional stress level and bounce back quickly from high stress situations.

With that in mind, let’s look at the “Functional Stress levels.”

Functional Stress: Stress levels 4, 5 & 6 designate the zone of functional stress. They are coded green because green is a color that represents “go”.  At stress levels 4, 5, and 6 we are experiencing stress levels that are high enough to give us the energy to get started, keep going, and get things done. The stress, however, is not so high that in interferes with what we are doing.

  • Stress Level 4: With effort we get Focused and Active.
  • Stress Level 5: We operate at high performance, a state of free flow with little or no effort.
  • Stress level 6: We can keep on going but it takes effort and we notice we are getting tired. It’s called free flow with effort. This is a good time to take a short break if you can to get your stress level back down to a level five.

Acute Stress Reaction: Stress levels 7, 8, and 9 are coded yellow. The color yellow represents caution. At stress levels 7, 8, and 9 we are experiencing an acute stress reaction. The word “acute” means immediate and severe. The good thing about acute stress is that if we notice it early and know how to relax, by taking a short break and using a relaxed breathing technique for example, we can lower our stress and get back into the functional zone. When we enter stress level 7 it means that our immediate levels of stress have gotten so high that we can’t consistently function normally. We’re in danger.

  • Stress level 7: Space Out: at a stress level 7 we space out. Our mind goes somewhere else and we don’t even know we were gone until our mind comes back on task.
  • Stress level 8: Driven and Defensive: at stress level eight we are driven and defensive. Our stress chemical has been activated and we are running on an adrenaline rush that is keeping us compulsively on task. The problem is that if someone or something interrupts us we become defensive and can easily move into stress level 9.
  • Stress level 9: Overreaction/Survival Behavior: at stress level 9 our automatic survival behavior takes over. The three basic survival behaviors that everyone has are: fight (irritated, angry, agitated); flight (anxious, fearful, panicked); and freeze (we feel an agitated sense of depression and indecision. We freeze up and can’t make a decision or move.) On top of these three core survival behaviors we learn more sophisticated survival behaviors from our family of origin, life experiences, education or special training in stress management, emergency management, martial arts, or combat. For that training to automatically come into play, we must have practiced it over-and-over again until it became habitual. In sports, emergency services, police work, and military operations these are called trained response. When our stress hits level ten our brain won’t allow us to rise to the situation. The emergency brain response will always lower us to the level of our training. In an emergency, all we can rely on are our automatic responses that we learned to perform on cue without having to think about it.

Traumatic Stress Reaction: Stress levels 10, 15, and 20 are coded red. Red is for stop. At this point our stress levels are so high that our brains and minds are at risk of shutting down. There are three levels of stress that can occur in the red zone of traumatic stress.

  • Stress level 10: Loss of Control: We automatically start using our survival behavior and we can’t control it. We are on automatic pilot and we will go through our learned survival responses one-by-one. This means we will cycle through stages of extreme anger (fight), extreme fear (flight, and extreme inner conflict or ambivalence (freeze). It is important to remember that all people with serious alcohol and drug problems have conditioned themselves with a survival behavior called “seek and use drugs to handle this.” So it is not unusual for a person at a stress level ten to get into drug seeking behavior and start using alcohol or other drugs.
  • Stress level 15: Traumatic Stress: At level 15 our high stress overloads the brain and we mentally disconnect from what is happening to us. Our stress is so high that we can’t stay consciously connected with out bodies. We may go into a state of daze, shock, and dissociation. Our mind can start to play tricks on us and things around us may seem bigger, or closer or farther away than they really are. We may start feeling confused and disoriented. It may seem like we are moving in slow motion. Some people feel like they have floated out of their bodies and it seems like they are watching themselves go through the experience.
  • Stress level 20: Collapse/Psychosis: When our stress levels hit a level 20 our brains can’t take the high level of stress and fatigue. We may collapse, enter an exhausted state of stupor or restless sleep, move into a vivid fantasy world or a world of memories or dreams, or become unconscious.

Any time people experience a “level 10 plus” state of stress; it will take a while after the stress stops for our brain to start functioning normally. When this is a short-term period of adjustment it is called an “acute trauma reaction.” When in it is a longer-term reaction it is called post traumatic stress disorder.

If you have ever experienced a “level 10 plus” stress experience – which can happen when you are the victim of crime, accidents, caught in a burning house, participating in combat, having been assaulted, etc. – it is important to discuss these experiences with your doctor or therapist. This is especially important if the high stress experience you had causes problems that you did not have before it occurred.

The Stress Thermometer

Developed By Terence T. Gorski (© Terence T. Gorski, 2011)
www.cenaps.com; www.relapse.org; www.facebook.com/GorskiRecovery

Level 20: Dissociation/Unconsciousness: I get dissociated and feel like I am floating out of my body. Things seem unreal, and I eventual pass out.
Level 15: Traumatic Stress: Stress overloads the brain and we go into a state of daze, shock or dissociation. We may feel like we are floating out of our bodies and watching ourselves go through the experience.
Level 10: Lose Control: Fight = Anger-based, Flee = Fear-based, Freeze = Depression-based.
——————————–The Brain Shift Gears ——————————–
Level 9: Overreact: Anger, fear, or compulsion get out control & starts running our intellect.
Level 8: Get Defensive: Automatic defenses are used; we start acting out compulsively. The ability to think becomes a servant to hidden fear, anger, & depression. Strong craving and urges to fight, run, hide, find a rescuer, blame others, or lose motivation & hope.
Level 7: Space Out: My brain can’t handle the stress, turns off for a second, and I gone blank and don’t even realize it until my brain turns back on a few seconds later.
——————————– The Brain Shift Gears ——————————–
Level 6: Free Flow Activity With Effort I’m getting tired and have to push myself to keep going.
Level 5: Free Flow Activity With No Effort: I’m totally into what I’m doing and get lost in the process. I’m on automatic pilot.
Level 4: Become Focused and Active With Effort: I make a decision to dig in and get to work. It takes an effort to get started.
——————————– The Brain Shift Gears ——————————–
Level 3: Relaxed – Aware But Not Focused: I’m relaxed and aware of what’s going on around me. I’m beginning to realize that I need to get going.
Level 2: Very Relaxed – Not Aware & Not Focused: I’m so relaxed that I’m not aware of what’s going on around me. I’m disconnected and don’t want to notice anything.
Level 1: Deeply Relaxed – Nearly Asleep: I’m so deeply relaxed that I’m drifting in and out of a dreamy type of sleep state filled with active fantasy or daydreaming.
The Most Important Stress Management Tool is
The Conscious Awareness of the Rise and Fall of Your Stress Levels.
This is Achieved Through Self-monitoring.

 

Measuring Levels of Stress

Notice that you are measuring your personal perception of stress, which is a combination of three things: (1) the intensity of the stressor (the situation activating stress); (2) your ability to cope with or handle the stressor; and (3) your level of awareness while you are experiencing the stress.

It is possible for you to score yourself very low on the stress thermometer even when your stress is very high. This can happen because: (1) you are distracted and involved in something else (like managing the crisis causing your stress); (2) your stress is so high that you are emotionally numb and don’t know what you are feeling; (3) if you have lived with such high stress for such a long time that you consider it normal; and (4) you have trained yourself to ignore your stress.

The first step in learning how to manage your stress is to learn how to recognize and evaluate your level of stress and by learning how to quickly get back into a low stress level by using a Relaxed Breathing Technique. Let’s start by looking at how you can improve your stress awareness.

 

Improving Stress Awareness

The best way to learn to be aware of your stress level is to get in the habit of consciously monitoring your stress level. You can do this by using a mental tool called The Stress Thermometer, (page 17). The first step is to imagine that you have an internal stress thermometer that starts in the pit of your stomach and ends in your throat. The lowest reading on the stress thermometer is zero and represents a deep sense of relaxation that is so complete that you want to fall asleep. At a stress level seven or eight, your stress becomes so intense that you start shutting down, getting defensive, or avoiding the issue that is causing the stress. If you can’t manage or get away from the stressful situation, at a level ten you lose control and start believing that you can’t handle the situation and that you or someone you love may be hurt or killed. These extreme feelings of stress are called trauma.

When most people hit a stress level of seven or higher they are not able to respond to constructive criticism or to make sense out of their emotional experiences. At stress levels between seven and nine most people start acting compulsively, overreact to things going on around them, and start using automatic habitual survival behaviors that may or may not solve the problem and lower stress.

This is why it is so important for you to learn to recognize your stress levels when they start hitting a level seven and learn how to quickly lower them. You can do this by using an immediate relaxation response technique called Relaxed Breathing any time you notice your stress hitting a level seven or above. So you have four goals in this exercise:

(1)        To learn how to get into the habit of noticing when your stress is getting up to a level seven or eight;

(2)        To learn how to quickly lower your stress by using the Relaxed Breathing Technique;

(3)        To figure out what is happening and how you are thinking and feeling about what is happening that is causing your stress to go up; and

(4)        Manage the stressful situation by responsibly getting out of the situation or learning how to manage your thoughts, feelings, and behaviors that will allow you to stay cool and relaxed even tough you are in a tough situation.

Monitoring Your Stress – Body Awareness

Body awareness is a technique that allows you to recognize how your body physically reacts to stress. It can be a powerful skill to use in stress management because as you notice the stress in different parts of your body, you will start to relax the part of the body you are noticing. With enough practice your body will automatically start identifying and releasing stress before you become consciously aware of it. Muscle tension is the primary way your body let’s you know that you are experiencing stress. Consciously using a systematic body awareness technique whenever you think about it and at least four times per day will start you on the road to teaching your body to automatically recognize and release stress. Here’s how the technique works:

Begin by closing your eyes. You will concentrate on one muscle group at a time, tensing and releasing and being aware of how tight the muscle is as you focus on it. If the muscle feels tight as you begin, this may indicate you store stress in this muscle. Begin with focusing on your toes and slowly move up your body. Tighten your toes and release, flex your calves and release, tighten your thighs and release, tighten your stomach muscles and release, fist your hands and release, tense your shoulders and release, clench you jaw and release, squint your eyes and scrunch your face and release. Any time you encounter tension in a muscle, record that muscle tension and be aware that you are holding stress there. This will help you in developing a personal stress reduction plan and using exercises and techniques to release pent-up tension.

Reducing Your Stress – Relaxed Breathing

There are a number of different relaxation methods. For the purpose of this workbook I am going to teach the easiest and most effective. It is called Relaxed Breathing. It is so effective that military, police and firefighters are taught to use it to lower their stress when responding to emergencies. Here’s how it works:

Relaxed Breathing, often called combat breathing in the military or tactical breath by police and emergency responders, is designed for both before and during stressful times to calm you down and help you relax. In terms of the stress thermometer, relaxed breathing is used before a stressful situation to calm you down and get you ready to be at your best. It is used during a stressful situation to keep your stress from going above that critical Level 7, where your brain turns off and automatic defensive behavior and cravings kick in.

Early in recovery, thinking about and talking about your use of alcohol or other drugs will cause some of your highest stress. The catch 22 is this – if you don’t talk about it, the thoughts will keep coming back like a ghost in the night that haunts moments that should be quiet and restful. Each time you expel the ghost by refusing to think and talk about the “real problems” the ghost goes away for a little while and comes back stronger. Your denial and resistance is strengthened, the intensity of your craving goes up, and your ability to think rationality about what you need to do goes down. As a result the voice of this “stress ghost” grows into a full-blown “stress monster” that can literally take your brain hostage and make you believe that self-medication with alcohol or other drugs is the best or only way to get back in control of yourself and your life.

Step 1: The first thing you need to do is to convince yourself that you can manage and reduce stress without having to self-medicate. There is another way. That way involves learning how to control your breathing.

Step 2: Practice relaxed breathing in a safe environment when you are not stressed. Just go through the steps and get used to them.

Step 3: Get used to rating your stress level. Initially you may need to use the stress thermometer, but with a few times of practice (four times per day for three or more days) the use of the scale will be an automatic tool that you will use whenever you check out you stress level.

Step 4: Take control of the process by stressing yourself out and then relaxing yourself using the relaxed breathing technique.

Sit in a quiet place where you will not be disturbed for ten or fifteen minutes. Take a deep breath and do a quick body checks. Then on a sheet of paper write the word START and underneath or next to it rate your stress level.

For example, I would do a body check and write: START = 6. I am still relaxed and able to think and respond, but I am tired and on the edge of spacing out.

Step 5: Stress yourself out! Your heard what I said. Think about the things you usually think about that raise your stress. Be sure to beat yourself up about your drinking and drugging, how stupid you were, the problems it has caused and how you will never-ever be able to repair the damage you have done to your life. Stop the process before your stress hits a level 9 or 10 and you go running out of the room. Then write the words: AFTER STRESS and rate your stress level. Most people find it easy to raise their stress.

For example, after beating myself up for about 60 seconds I would write: AFTER STRESS = 8. I feel myself driving myself and notice the thoughts start to take on a life of their own. If someone interrupts me at this moment I could easily over-react.

Step 6: Relax yourself! You heard me. Do what you need to do to relax. This is the problem for many people, especially people who use alcohol, prescribed medication, or other drugs regularly and heavily. They can stress themselves out easily enough, but other than self-medication they have no way to calm themselves down. So try this:

Take a deep breath and hold it for a moment until your lungs feel just a little uncomfortable, hold your breath for a moment, and then exhale all the way out. Hold your breath for a moment with your lungs empty and then slowly inhale again. Start to breath a slow rhythmic count of four: “INHALE– two- three – four; HOLD – two – three – four; EXHALE – two – three – four; HOLD – two – three – four. Then start the cycle over by inhaling to the count of four. Repeat the cycle five times. Imagine the stress gathering in your lungs as you inhale and hold. Imagine the stress releasing from your mouth as you exhale and hold. That’s it.

Now rate your stress again. Look at the stress thermometer and see what happened. Then write the words: AFTER followed by your stress rating.

For example I would write: AFTER RELAXING = 4 (remember I’ve been practicing a long time). So the record of my session looks like this:

START =6; AFTER STRESS = 8; BREATHING REPS = 5; AFTER =4.

Don’t force yourself to relax, just do the relaxed breathing, and focus on counting and imaging the stress leaving your body ever time you exhale.

Practice four times per day, at breakfast, lunch, dinner, and before bed. Keep track of your progress. Use relaxed breathing if you notice your stress going up during any of the following exercises.

Footnotes

[i] Stress and increased Relapse Risk: Stress is an important factor known to increase alcohol and drug relapse risk. This paper examines the stress-related processes that influence addiction relapse. First, individual patient vignettes of stress- and cue-related situations that increase drug seeking and relapse susceptibility are presented. Next, empirical findings from human laboratory and brain-imaging studies that are consistent with clinical observations and support the specific role of stress processes in the drug-craving state are reviewed. Recent findings on differences in stress responsivity in addicted versus matched community social drinkers are reviewed to demonstrate alterations in stress pathways that could explain the significant contribution of stress-related mechanisms on craving and relapse susceptibility. Finally, significant implications of these findings for clinical practice are discussed, with a specific focus on the development of novel interventions that target stress processes and drug craving to improve addiction relapse outcomes.

  • Reference: The role of stress in addiction relapse. Curr Psychiatry Rep.  2007; 9(5):388-95 (ISSN: 1523-3812) Sinha R. Department of Psychiatry, Yale University School of Medicine, 34 Park Street, Room S110, New Haven, CT 06519, USA
  • Stress Identification and Management: Stress as verified by clinical observations, patient self-reports, and subjective and behavioral measures have been correlated depressive symptoms, stress, and drug craving during withdrawal. All of theses factors predict future relapse risk. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal

[ii] Stress Identification and Management: Stress as verified by clinical observations, patient self-reports, and subjective and behavioral measures have been correlated depressive symptoms, stress, and drug craving during withdrawal. All of these factors predict future relapse risk. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal.

[iii] The Role of Stress In Addiction: Both animal and human studies demonstrate that stress plays a major role in the process of alcohol and drug addiction and that a variety of stressors can increase both self-reported stress and measures of biological stress. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal.

Reference: New findings on biological factors predicting addiction relapse vulnerability. Curr Psychiatry Rep.  2011; 13(5):398-405 (ISSN: 1535-1645) INTERNET: http://reference.medscape.com/medline/abstract/21792580

[iv] Stress and Addiction: Stress plays a major role in the process of drug addiction and various stressors are known to increase measures of craving in drug dependent human laboratory subjects. Animal models of stress-induced reinstatement of drug-seeking have also been developed in order to determine the neuropharmacological and neurobiological features of stress-induced relapse.

  • Reference: Pharmacologically-induced stress: a cross-species probe for translational research in drug addiction and relapse. Am J Transl Res.  2010; 3(1):81-9 (ISSN: 1991) See RE; Waters RP. Department of Neurosciences, Medical University of South Carolina, Charleston SC USA.

[v] Stress-Induced Craving and Cognitive Behavioral Therapy: The Division of Clinical Neuroscience, Medical University of South Carolina, Charleston, South Carolina 29425, USA. (backs@musc.edu) has found that stress-induced craving and stress reactivity may influence risk for substance use or relapse to use. Interventions designed to manage stress-induced craving and stress reactivity may serve as excellent adjuncts to more comprehensive treatment programs. The purpose of this study was to (1) tailor an existing, manualized, cognitive-behavioral stress management (CBSM) intervention for use in individuals with substance use disorders and (2) preliminarily evaluate the effects of the intervention using an experimental stress-induction paradigm. Twenty individuals were interviewed and then completed a psychological stress task, the Mental Arithmetic Task (MAT). After this, participants were assigned to either the CBSM intervention group or a non-treatment comparison group. Approximately 3 weeks later, participants completed a second MAT. In contrast to the comparison group, the CBSM group demonstrated significantly less stress-induced craving (p<.04) and stress (p<.02), and reported greater ability to resist urges to use (p<.02) after the second MAT. These findings are among the first to report on the use of an intervention to attenuate craving and stress reactivity among individuals with substance use disorders. Although preliminary, the findings suggest that systematic investigation of interventions specifically targeting stress management in individuals with substance use disorders should be undertaken.

  • Reference: Source: Back SE, Gentilin S, Brady KT. Cognitive-behavioral stress management for individuals with substance use disorders: a pilot study J Nerv Ment Dis. 2007 Aug;195(8):662-8

[vi] Research Society On Alcoholism: This report of the proceedings of a symposium presented at the 2004 Research Society on Alcoholism Meeting provides evidence linking stress during sobriety to craving that increases the risk for relapse. The initial presentation by Rajita Sinha summarized clinical evidence for the hypothesis that there is an increased sensitivity to stress-induced craving in alcoholics. During early abstinence, alcoholics who were confronted with stressful circumstances showed increased susceptibility for relapse. George Breese presented data demonstrating that stress could substitute for repeated withdrawals from chronic ethanol to induce anxiety-like behavior. This persistent adaptive change induced by multiple withdrawals allowed stress to induce an anxiety-like response that was absent in animals that were not previously exposed to chronic ethanol. Subsequently, Amanda Roberts reviewed evidence that increased drinking induced by stress was dependent on corticotrophin-releasing factor (CRF). In addition, rats that were stressed during protracted abstinence exhibited anxiety-like behavior that was also dependent on CRF. Christopher Dayas indicated that stress increases the reinstatement of an alcohol-related cue. Moreover, this effect was enhanced by previous alcohol dependence. These interactive effects between stress and alcohol-related environmental stimuli depended on concurrent activation of endogenous opioid and CRF systems. A.D. Lê covered information that indicated that stress facilitated reinstatement to alcohol responding and summarized the influence of multiple deprivations on this interaction. David Overstreet provided evidence that restraint stress during repeated alcohol deprivations increases voluntary drinking in alcohol-preferring (P) rats that result in withdrawal-induced anxiety that is not observed in the absence of stress. Testing of drugs on the stress-induced voluntary drinking implicated serotonin and CRF involvement in the sensitized response. Collectively, the presentations provided convincing support for an involvement of stress in the cause of relapse and continuing alcohol abuse and suggested novel pharmacological approaches for treating relapse induced by stress.

  • Reference: George R. Breese, Kathleen Chu, Christopher V. Dayas, Douglas Funk, Darin J. Knapp, George F. Koob, Dzung Anh Lê, Laura E. O’Dell, David H. Overstreet, Amanda J. Roberts, Rajita Sinha, Glenn R. Valdez, and Friedbert Weiss. Stress Enhancement of Craving During Sobriety: A Risk for Relapse, Alcohol Clin Exp Res. 2005 February; 29(2): 185–195.

See the related blog: Stress Self-Monitoring and Relapse

Stress Management Is Used In The Gorski Relapse Prevention Certification School (RPCS)

Relaxation Training and Mindfulness Meditation are a big part of Relapse Prevention Therapy (RPT). When patients are under high levels of stress, their ability to understand, integrate, and use new skills is diminished. Gorski RPT teaches therapists how to use a form of immediate relaxation training to keep clien’s stress low during the session. It also teaches them to use relaxation methods in the moment so they are more likely to use them in real-life events. For an overview of how relaxation training and a simple tool called the stress thermometer can be used with RPT check out Terry Gorski’s Blog:

GORSKI’S RELAPSE PREVENTION CERTIFICATION SCHOOL (RPCS)
November 10 -14, 2014 at the Hyatt Regency Pier Sixty Six

2301 SE 17th Street Causeway, Fort Lauderdale, FL 33316
For further information: Tresa Watson: 352-596-8000, tresa@cenaps.com 

SEE RELATED BLOGS:
Stress Self-Monitoring and Relapse ,
The CENAPS Model and Mindfulness in Relapse Prevention,  and
Mindfulness Made Simple.


Family and Relapse

July 30, 2014
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Families Recover Together

By Terence T. Gorski
Author and Trainer

This Article is excerpted from: “Staying Sober- A Guide To Relapse Prevention By: Terence T. Gorski

In many cases the addict is the first family member to seek treatment. Other family members become involved in order to help the alcoholic get sober. Many family members refuse to consider the fact that they also have a problem that requires specialized treatment. These family members tend to deny their role in their addicted family and scapegoat personal and family problems upon the addicted person. They develop unrealistic expectations of how family life will improve with their loved one getting abstinent. When these expectations are not met, they blame the addict for the failure, even though he or she may be successfully following a recovery program. Their attitudes and behaviors can become such complicating factors in the addict’s recovery that they can contribute to the process of relapse and even “set-up” the addict’s next “episode of use.”

On the other hand family members can be powerful allies in helping the addict prevent fully engaging the relapse process. Relapse Prevention Planning utilizes the family’s motivation to get the addict sober. As family members become involved in relapse prevention planning, a strong focus is placed upon co-addiction and its role in the family relapse process. Family members are helped to recognize their own co-addiction and become actively involved in their own treatment. Addiction is a family disease that affects all family members, requiring everyone to get involved in treatment. The addict needs treatment for addiction. Other family members need treatment for co-addiction.

The term “co-addiction” is sometimes used to refer only to the spouse of an addict and other terms are used to refer to other family members. We are using the term “co-addict” to refer to ANYONE WHOSE LIFE HAS BECOME UNMANAGEABLE AS A RESULT OF LIVING IN A COMMITTED RELATIONSHIP WITH AN ADDICTED PERSON.

Co-addiction is a definable syndrome that is chronic and follows a predictable progression. When persons in a committed relationship with an addicted person attempt to control drinking, drug use, or addictive behavior (over which they are powerless), they lose control over their own behavior (over which they can have power) and their lives become unmanageable.

When you try to control
What you are powerless over
You lose control
Over what you can manage.

The person suffering from co-addiction develops physical, psychological, and social symptoms as a result of attempting to adapt to and compensate for the debilitating effects of the stress of living with someone who is addicted. As the co-addiction progresses, the stress-related symptoms become habitual. The symptoms also become self-reinforcing; that is, the presence of one symptom of co-addiction will automatically trigger other co-addiction symptoms. The co-addiction eventually becomes independent of the addiction that originally caused it. The symptoms of co-addiction will continue even if the addicted person in the family becomes sober or joins AA/NA, or the co-addict ends the relationship.

The condition of co-addiction manifests itself in three stages of progression.

Early Stage: Normal Problem Solving and Attempts to Adjust

The normal reaction within any family to pain, to crisis, and to the dysfunction of one member of the family is to do what they can to reduce the pain, ease the crisis, and to assist the dysfunctional member however possible in order to protect the family. These responses do not make things better when the problem is addiction, because these measures deprive the addicted person of the painful learning experiences that bring an awareness that his/her addiction is creating problems. At this stage, co-addiction is simply a reaction to the symptoms of addictive disease. It is a normal response to an abnormal situation.

Middle Stage: Habitual Self-Defeating Responses

When the culturally prescribed responses to stress and crisis do no bring relief from the pain created by the addiction in the family, the family members TRY HARDER. They do the same things, only more often, more intensely, mores desperately. They try to be more supportive, more helpful, more protective. They take on the responsibilities of the addicted person, not realizing that this causes the addict to become more irresponsible.

Things get worse instead of better and the sense of failure intensifies the response. Family members experience frustration, anxiety, and guilt. There is growing self-blame, lowering of self-concept, and self-defeating behaviors. They become isolated. They focus on the addict’s addictive behavior and their attempt to control it. They have little time to focus on anything else. As a result they often lose touch with the normal world outside of their family.

Chronic Stage: Family Collapse and Stress Degeneration

The continued habitual response to addiction in the family results in specific repetitive, circular patterns of self-defeating behavior. These behavior patterns are independent and self-reinforcing and will persist even in the absence of the symptoms of addictive disease.

The things the family members have done in a sincere effort to help have failed. The resulting despair and guilt bring about confusion and chaos and the inability to interrupt dysfunctional behavior even when they are aware that what they are doing is not helping. The thinking and behavior of the co-addict is OUT OF CONTROL, and these thinking and behavior patterns will continue independent of the addiction.

Co-addict degeneration is bio-psycho-social. The ineffective attempts to control drinking and drugging behavior elevate chronic stress to the point of producing stress-related physical illnesses such as migraine headaches, ulcers, and hypertension. This chronic stress may also result in a nervous breakdown or other emotional illnesses. Out-of-control behavior itself is an addiction-centered lifestyle that pervades all life activity, even that which seems unrelated to the addiction. Social degeneration occurs as the addiction focus interferes with relationships and social activity. Spiritual degeneration results, as the focus on the problem becomes so pervasive that there is no interest in anything beyond it, particularly concerns and need related to a higher meaning of life.

Recovery from co-addiction means learning to accept and detach from the symptoms of addiction. It means learning to manage and control the symptoms of co-addiction. It means learning to focus on personal needs and personal growth, learning to respect and like oneself. It means learning to choose appropriate behavior. It means learning to be in control of one’s own life.

Because it is a chronic condition, co-addiction, like addiction, is subject to relapse. But a condition of co-addict relapse may be more difficult to identify. Without an ongoing recovery program and proper care of oneself, old feelings and behaviors thought to be under control may surface and become out of control. Life again becomes unmanageable; the co-addict is in relapse mode.

RELAPSE WARNING SIGNS FOR CO-ADDICTION

From the observation of counselors who have worked with recovering family members, relapse warning signs for the co-addicted significant other have emerged. The following list has been compiled from these observations.

1. Situational Loss of Daily Structure. The family member’s daily routine is interrupted by a temporary situation such as illness, the children’s schedule, the holidays, vacation, etc. After the event or illness, the significant other does not return to all of the activities of his or her recovery program.

2. Lack of Personal Care. The significant other becomes careless about personal appearance and may stop doing and enjoying small things that are “just for own personal enjoyment.” The person returns to taking care of others first and self second or third.

3. Inability to Effectively Set and Maintain Limits. The significant other begins to experience behavioral problems with the children or roommates. Limits that are being set tend to be too lenient or too rigid and result in more discipline problems.

4. Loss of Constructive Planning. The significant other begins to feel confused and overwhelmed by personal responsibilities. Instead of deciding what is most important and doing that, he or she begins to react by doing the first thing that presents itself, while more important jobs go undone.

5. Indecision. The significant other becomes more and more unable to make decisions related to daily life.

6. Compulsive Behavior. The significant other experiences episodes during which he or she feels driven to do more. Whatever has already been done does not seem to be enough.

7. Fatigue or Lack of Rest. He or she becomes unable to sleep the number of hours necessary to feel rested. When sleep does occur, it is fitful.

8. Return of Unreasonable Resentments. The significant other finds himself or herself mentally reviewing persons or events that have hurt, angered, or been generally upsetting. As these are reviewed, the significant other relives the old emotions and feels resentments about them.

9. Return of the Tendency to Control People, Situations, and Things. As the co-addicted significant other feels less control over life, he or she begins openly to try to control and manipulate other people or situations. The addicted person may be the prime target, but does not necessarily have to be.

10. Defensiveness. The co-addicted person may not totally approve of some of his or her own actions, but when challenged about them will openly justify the actions in a sharp or angry way.

11. Self-Pity. The co-addict begins to dwell on problems from the present or the past and in turn begins to magnify them. The significant other person may ask, “Why does everything always happen to me?”

12. Overspending/Worrying about Money. The significant other may be very concerned about the family finances, yet impulsively spends money in order to “feel better.” He or she becomes convinced that what was purchased was deserved, but ends up feeling guilty and even more trapped.

13. Eating Disorder. The significant other “loses” his or her appetite to the point that even favorite foods are not appealing. Or the significant other may begin to overeat, regardless of appetite, in order to feel better. The overeating satisfies for only a very short time, or not at all.

14. Scapegoating. There is an increasing tendency to place the blame on other people, places, and things. The co-addict looks outside of self for the reasons why he or she is feeling bad.

15. Return of Fear and General Anxiety. The significant other begins to experience periods of time when he or she is nervous. Situations that previously did not cause fear or anxiety are now causing those emotions. The significant other may not even know the source of the nervousness.

16. Loss of Belief in a Higher Power. The significant other begins to lose belief in a higher power, whatever it may be. There is a tendency to rely more on self-alone, or to turn to the addict for strength and the solutions.

17. Attendance at Al-Anon Becomes Sporadic. The significant other changes the pattern of Al-Anon meeting attendance. He or she may go to fewer meetings, thinking there isn’t time, the meetings aren’t helping, or are not needed.

18. Mind Racing. The significant other feels as though he or she is on a treadmill that is going too fast. In spite of attempts to slow down, the mind continues to race with the many things that are undone or the problems that are unsolved.

19. Inability to Construct a Logical Chain of Thought. The significant other tries to solve problems and gets stuck on something that would normally be simple. It seems that his or her mind does not work anymore, that it is impossible to figure out the world. As a result, he or she feels powerless and frustrated with life.

20. Confusion. The significant other knows they are feeling out-of-sorts, but don’t know what is actually wrong.

21. Sleep Disturbance. Sleeplessness or fitful nights become more regular. The more the person tries to sleep, the less he or she is able to. Sleep may come, but it is not restful. The significant other looks tired in the morning instead of rested.

22. Artificial Emotion. The co-addict significant other begins to exhibit feelings without a conscious knowledge of why. He or she may become emotional for no reason at all.

23. Behavioral Loss of Control. The co-addict begins to lose control of his or her temper especially around the addict and/or the children or roommates. Loss of behavioral control is exhibited in such ways as over-punishing the children, hitting and yelling at the addict, or throwing things and tantrums.

24. Uncontrollable Mood Swings. Changes in the co-addict’s moods happen without any warning. The shifts are dramatic. He or she no longer feels somewhat down or somewhat happy, but instead goes from feeling extremely happy to extremely low.

25. Failure to Maintain Interpersonal (Informal) Support Systems. The co-addict stops reaching out to friends and family. This may happen very gradually. He or she turns down invitations for coffee, misses’ family gatherings, and no longer makes or returns phone calls.

26. Feelings of Loneliness and Isolation. The co-addict begins to spend more time alone. He or she usually rationalizes this behavior – too busy, the children, school, job, etc. Instead of dealing with the loneliness, the co-addict becomes more compulsive and impulsive. The isolation may be justified by convincing him or herself that no one understands or really cares.

27. Tunnel Vision. No matter what the issue or situation might be, the co-addict focuses in on his or her opinion or decision and is unable to see other points of view. He or she may become close-minded.

28. Return of Periods of Free Floating Anxiety and/or Panic Attacks. The co-addict may begin to re-experience, or experience for the first time, waves of anxiety that seem to occur for no specific reason. He or she may feel afraid and not know why. These uncontrollable feelings may snowball to the point that he or she is living in fear of fear.

29. Health Problems. Physical problems begin to occur such as headaches, migraines, stomach aches, chest pains, rashes, or allergies.

30. Use of Medication or Alcohol as a Means to Cope. Desperate to gain some kind of relief from the physical and/or emotional pain, the co-addict may begin to drink, use drugs, or take prescription medications. The alcohol or drug use provides temporary relief from the growing problems.

31. Total Abandonment of Support Meetings and Therapy Sessions. Due to a variety of reasons (belief that he or she no longer needs the meetings, immobilizing fear, resentment, etc.), the co-addict completely stops going to support meetings or to therapy or both.

32. Inability to change self-defeating behaviors. While there is recognition by the co-addict that what is being done is not good for himself or herself, there is still the compulsion to continue the behavior in spite of that knowledge.

33. Development of an “I Don’t Care” Attitude. It is easier to believe that “I don’t care” than it is to believe that “I am out of control.” In order to defend self-esteem, the co-addict rationalizes, “I don’t care.” As a result, a shift in value system occurs. Things that were once important now seem to be ignored.

34. Complete Loss of Daily Structure. The co-addict loses the belief that an orderly life is possible. He or she begins missing (forgetting) appointments or meetings, is unable to have scheduled meals, to go to bed or get up on time. The co-addict is unable to perform simple acts of daily function.

35. Despair and Suicidal Ideation. The co-addict begins to believe that the situation is hopeless. He or she feels that options are reduced to two or three choices: going insane, committing suicide, or numbing out with medication, and/or alcohol, drugs or maladaptive, perhaps compulsive behavior.

36. Major Physical Collapse. The physical symptoms become so severe that medical attention is required. These can be any of a number of symptoms that become so severe that they render the co-addict dysfunctional (e.g., an ulcer, migraines, heart pains, or heart palpitations).

37. Major Emotional Collapse. Having seemingly tried everything to cope, the co-addict can conceive no way to deal with his or her unmanageable life. At this point the co-addict may be so depressed, hostile, or anxious that he or she is completely out of control.

RELAPSE PREVENTION FOR THE FAMILY

While each family member is responsible for his or her own recovery and no one can recover for another, the symptoms of addiction and co-addiction each impact upon the relapse potential of the other. Even if the alcoholic/addict is no longer drinking or using and no longer experiencing the alcohol/drug-related symptoms of the disease, the post acute withdrawal symptoms affect and are affected by co-addiction. Both the symptoms of post acute withdrawal and the symptoms of co-addiction are stress sensitive. Stress intensifies the symptoms and the symptoms intensify stress. As a result, the recovering addict and the co-addict can become a stress-generating team that unknowingly and unconsciously complicates each other’s recovery and create a high risk of relapse.
What can family members do to reduce the risk of their own relapse and the risk of relapse in the recovering addict? They can become informed about the addictive disease, recovery, and the symptoms that accompany recovery. They must recognize that the symptoms of post acute withdrawal are sobriety-based symptoms of addiction rather than character defects, emotional disturbances, or mental illness. At the same time they must accept and recognize the symptoms of co-addiction and become involved in Al-Anon and/or personal therapy as they develop plans for their own recovery.
Clinical experience with relapse prevention planning in a variety of treatment programs has indicated that the family can be a powerful ally in preventing relapse in the addict. In 1980, relapse prevention planning was modified to include the involvement of significant others including family members. This significantly increased effectiveness. With further clinical experience, however, other problems became apparent. Many family members refused to participate in relapse prevention planning. Other family members participated in a manner that was counterproductive.

In 1983 relapse prevention planning was expanded to include relapse prevention in both the addicted person and the co-addict. The newly designed relapse prevention planning protocol utilizes the family’s motivation to get the addict sober. As family members become involved in relapse prevention planning, a strong focus is placed upon co-addiction and its role in family relapse.

Family members are helped to recognize their own co-addiction and become actively involved in their own treatment. Addiction is presented as a family disease that affects all family members requiring them to get treatment.

All members of an addicted family are prone to return to self-defeating behaviors that can cause them to become out of control. An acute relapse episode can occur with an addict or a co-addict family member.

Like addicts who develop serious problems even though they never use alcohol or drugs, the co-addict often becomes dysfunctional even though the addict is sober and working an active recovery program.

It is important to protect the family from the stress that may be generated by the symptoms of post acute withdrawal experiences by the recovering person and to cooperate in plans to protect the recovering person from stress created by symptoms of co-addiction.

Remember that none of you became ill overnight. Recovery will, likewise, take place over a long period of time. Develop a plan to prevent personal relapse and support relapse prevention plans for the recovering addict.

Family Relapse Prevention Planning is intended to help prevent acute relapse episodes in the recovering addict, to prevent crisis in the co-addict, to develop a relapse prevention plan for both the addict and co-addict and to develop an early intervention plan to interrupt acute relapse episodes in both the recovering addict and the co-addict. For the addict this involves interrupting problems that are caused both by Post Acute Withdrawal (PAW) Syndrome in the sober addict and by alcohol or drug use in the addict who has returned to drinking or using. For the co-addict this involves interrupting the co-addiction crisis.

The family needs to work with a counselor to establish a formal relapse prevention plan that will allow them to support each other’s recovery and to help intervene if the relapse warning symptoms get out of control.

The family relapse prevention planning protocol consists of twelve basic procedures. These are:

1. Stabilization: The first step in relapse prevention planning is to stabilize both the addict and the co-addict. The addict is stabilized through the process of detoxification or treatment of post-acute withdrawal symptoms. The spouse is stabilized by treating the co-addict crisis, through detachment from the addicts crisis, by regaining a reality-based perspective, and the development of some basic personal strengths. This often requires attendance at Al-Anon and professional counseling.

2. Assessment: Prior to developing a relapse prevention plan it is necessary to evaluate the addict, the co-addicts, and the family system. The evaluation should assess the current problems of each family member, their willingness and ability to initiate a personal recovery program, and their willingness to become involved in a program of family recovery.

3. Education about Alcoholism, Co-addiction, and Relapse: Accurate information is the most powerful of all recovery tools. The addict and the family must learn about the disease of addiction, the condition of co-addiction, treatment, and relapse prevention planning. This education is best provided to the family as a unit in multiple family classes. It is helpful if separate group therapy programs accompany the education for each family member. The addict should enter an addict group, the adult co-addict should enter a spouse’s group, and the co-addict children should enter a children’s group. It is in these group treatment sessions that individual recovery of all family members is initiated.

4. Warning Sign Identification: Both the addict and the co-addict need to identify the personal warning signs that indicate that they are becoming dysfunctional. Again, this is best done in a group setting. The addict is better able to identify relapse-warning signs when working with other addicts. Co-addicts are best able to initially identify relapse-warning signs when working with other co-addicts. Relapse warning sign lists for addiction and co-addiction are useful guides for personal warning sign identification.

5. Family Validation of Warning Signs: After each family member has developed a personal list of warning signs and reviewed these in his or her group, a series of family sessions is scheduled. During these sessions all family members present their personal lists of warning signs and ask for feedback. Other family members discuss the warning signs, help assess fi they are specific and observable. New warning signs may be added to the list based upon the feedback of others. Since each family member has a list of warning signs that precede acute relapse episodes there is no identified patient. All participate from a position of equality. They essentially say to each other, “We have all been equally affected, in various ways, by addictive disease.”

6. The Family Relapse Prevention Plan: Family members discuss each of their warning signs, how the family has dealt with those warning signs in the past, and what strategies could be effectively used in the future. Future situations in which the warning signs are likely to be encountered are identified. Strategies for more effective management of the warning signs for each family member are discussed. During this process a great deal of role playing and problem solving occurs. Problems are often identified that are taken back to the separate therapy groups for further work.

7. Inventory Training: All member of the family receive training in how to complete a morning planning inventory and an evening review inventory. These focus heavily upon time structuring, realistic goal setting, and problem solving.

8. Communication Training: The family members must learn to communicate effectively in order for a Relapse Prevention Plan to work. The family is trained in the process of giving and receiving feedback in a constructive and caring manner.

9. Review of the Recovery Program: All family members will report to the family the recovery program that they have established for themselves. This focus here is, “How will you and I know that I am doing well in my recovery?”
All are invited to express their recovery needs and point out their progress in treatment.

10. Denial Interruption Plan: Both addiction and co-addiction are diseases of denial. Most of the denial is unconscious. Neither the addict nor the co-addict realizes that they are in denial when it is happening. It is important to take the reality of denial into account early. Each family member should be asked the question, “What are other people in your family supposed to do if they give you feedback about concrete warning signs and you deny it, ignore the feedback, or become angry and upset?” Each family member should recommend specific plans for dealing with their own denial. This open discussion sets the stage for intervention should denial become a problem in the future.

11. The Relapse Early Intervention Plan: Addiction and co-addiction are prone to relapse. Relapse means becoming dysfunctional in recovery. For the recovering addict relapse may ultimately lead to alcohol and drug use, or it may simply mean that the person becomes so depressed, anxious, angry, or upset that he is dysfunctional in sobriety. For the co-addict relapse means the return to a state of co-addict crisis that interferes with normal functioning. Once family members enter an acute relapse episode they are out of control of their thoughts, emotions, judgements, and behavior. They often need the direct help of other family members to interrupt the crisis. Many times they resist this help. They act as if they do not want help even though they desperately need it. The family is instructed in the process of intervention. Intervention is a method of helping people who refuse to be helped. This intervention training has resulted in a radical decrease in the duration and severity of relapse episodes in family members.

12. Follow-up and Reinforcement: Addiction and co-addiction are life-long conditions. The symptoms can go into remission but they never totally disappear. They rest quietly, waiting for a lapse in the recovery program to become active again. It is important that the family maintain an ongoing recovery program including AA/NA, Al-Anon, and periodic relapse prevention checkups with a professional addiction counselor.

This Article is excerpted from: “Staying Sober- A Guide To Relapse Prevention By: Terence T. Gorski

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