Relapse Prevention Revisited

Terry Gorski pioneered the study of relapse prevention by his observation of people in recovery for substance use. He was the first to describe relapse as a process rather than an event. He helpfully defined relapse as “becoming dysfunctional in recovery”. He described nine stages of relapse.

Now, in a paper published in the Yale Journal of Bioloby and Medicine Steven Melemis has updated Gorski’s model by consolidating Gorski’s nine stages of relapse into three stages.

Melemis serves the recovering people here by simplying Gorski’s important congtribution to a more manageable model. While it is important for clinicians to understand Gorski’s stages, a person in recovery does well to remember three:

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  • Emotional
  • Mental
  • Physical
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In Emotional Relapse, a person is not thining about return to use. However, he becomes increasingly vulnerable to relapse. As in all addictive processes, an early sign of Emotional Relapse is denial. A person denies there is anything wrong.

Others see a difference. A person begins to isolate. He begins to bottle up emotions and avoid difficult situations and conversations. He stops healthy self-care practices. Sleep patterns change. Healthy relating deteriorates. More time may be spent at work as a way to avoid challenges at home.

Although the obsessive thinking associated with an addictive process has not returned, the conditions for obsessive thinking have.

To address Emotional Relapse raise awareness of the toll that is being taken on the person’s emotional health. Help the person explore explore self-care. Openly discuss the possibility that the person may be in denial of his own needs.

Terry Gorski recommends that before the cycle of relapse begins, that is, while a person is in healthy recovery, a recovering person does well to make a plan that will disrupt the relapse process. This involves giving trusted others permission — even the words to say — when they see an Emotional Relapse underway.

This may be where Gorski’s more refined description of relapse becomes helpful. Melemis’ Emotional Relapse are all about Gorski’s first seven steps in the relapse process. Gorski’s work has always been targeted at the recovering community. His style avoids clinical jargon and technical word that mean little to most people.

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  • Step 1: Getting Stuck In Recovery
  • Step 2: Denying That We’re Stuck
  • Step 3: Using Other Compulsions
  • Step 4: Experiencing A Trigger Event
  • Step 5: Becoming Dysfunctional On The Inside
  • Step 6: Becoming Dysfunctional On The Outside
  • Step 7: Loosing Control
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If a recovering person can acknowledge when they are stuck — by undermining a denial process — relapse is prevented. This where a relapse plan and a recovering person’s very own “relapse prevention team” can help. They stop the relapse cycle before it even begins.

Failing here, Melemis’ reminds us, leads to Mental Relapse.

Mental Relapse involves a return to addictive thinking. This is when thoughts about a return to use begins. First one may remember the good times, without association of the negative consequences associated with use. Terry Gorski calls this “euphoric recall”.

As the Mental Relapse progresses, thoughts begin to include self-bargaining, justification, and  planing return to use

Terry Gorski’s insight is that as the relapse cycle progresses, it becomes increasingly more difficult to stop.

When a person has passed through Emotional Relapse without having arrested the process, and entered Mental Relapse, the person has begun an menal issolation that includes rising shame. Disclosure of Mental Relapse becomes more difficult. Denial will be strong.

To address Mental Relapse the interventionist (whether a clincian, family member or friend) must create a safe place for self-disclosure. Inviting a person to share his throughts with a nonjudgmental attitude may be enough to interup the relapse process.

Physical Relapse is a return to the acting out behavior. Here the relapse cycle is complete.

Once again, Terry Gorski recommends that recovering people develop a relapse prevention plan that explicit gives trusted others permission to step into the process. At this stage, once again, it is important not to bring judgment and condemnation to the relationship. (The person is already judging and condemning himself.)

The intervention goal at this point is to help the person describe the acting out as a “lapse”. The difference between a lapse and relapse is the person’s ability to reclaim recovery goals, to reengage supportive relationship, and to deploy the recovery skills he has learned.

A person can learn from a lapse when he is supported by encouraging people who are able to listen the experience of the lapsed person who is helped to identify factors in the Emotional Relapse that were not addressed.

Melemis’s artical is a tinely refresher on what we know works well in relapse prevent. His article concludes with Five Rules of Recovery:

1. Change Your Life
2. Be Honest
3. Ask For Help
4. Practice Self-Care
5. Don’t Bend the Rules

Rule number 1, Change Your Life, is where recovery begins and ends. Recovery without relapse is not about getting stronger so you can go back to the way things were. Recovery without relapse recognizes that a new begins when you embrace the truth that no one is strong enough to life without attending to self-care in supportive relationships with others.

 

 

Image by Sam Sherratt