Relapse Prevention, Part 2

In my last post I wrote about triggers for relapse and the importance of having a relapse prevention plan, if you’re trying to establish and maintain a clean-and-sober lifestyle. The relapse prevention curriculum I developed in at the University Hospital of the West Indies in Jamaica included modules on stress  management, anger management, and rational thinking – all topics I’ve covered in previous posts. In this post I’ll be writing about other aspects of recovery from addiction.

I’ve met people with serious substance abuse problems who were too  proud to admit that they needed help in their recovery. (“I’m man enough to do it on my own!”) I’ve also known drug abusers who couldn’t imagine talking to other people – especially strangers – about addiction-related things they’d done and were ashamed of. But I’ve never met a recovering addict who got and stayed clean-and-sober without help from others, either in the form of professional help, or peer support groups such as AA. The road to recovery isn’t a road to walk alone.

Although I never saw him staggering drunk, my own father was an alcoholic. A military man who prided himself on his self-control, he once went for a year without drinking, to “prove” his ability to control his drinking. He went for exactly 365 days without a drink, but he hated every day of his self-imposed sobriety. It’s a condition known in the recovery community as “dry drunk.” As planned, on Day 366 he resumed drinking, moderately at first. But within weeks he was back to hiding bottles and drinking at the level he’d been drinking before his year of “white knuckle” sobriety.

There are individuals, I’m told, who’ve regained control of their excessive drinking and become moderate “social drinkers” – but I’ve never met one. “Someday I’ll be able to drink again” is a dangerous thought for people in recovery. Addicts are notorious for irrational thinking and self-deception. Many a relapse starts with thoughts like “I’ll allow myself one beer on my birthday” or “I can still shoot pool with my drinking buddies at the bar, and just drink sodas.” One of the arguments for attending Twelve Step meetings is that in time you’ll come to recognize your own rationalizations, by listening to other addicts who’ve come to recognize their own bullshit. Twelve Step meetings are all about getting real with other addicts who they know won’t judge them, because they’ve been there, done that, themselves.

Some friends and family of addicts don’t want to support their recovery, for a variety of reasons. Other well-meaning people who care about an addicted friend of family member become enablers. With the best of intentions, they try to shield their friends or  loved ones from the natural consequences of their addictions. They think they’re being helpful, but they’re simply enabling the person to continue drinking or using. In order to truly help, enablers need to learn to practice tough love – to stop attempting to rescue the person, and to let them suffer the natural consequences of their substance abuse. A mother practicing tough love won’t bail her son out of jail, because she knows from experience that if she does, he’ll be shooting up again within hours of his release.

Most recovering addicts come to the realization at some point in their recovery that they not only have to stop their drug-of-choice, but all intoxicating substances. I’ve known a number of crack and opioid addicts who initially believed that they could substitute alcohol and/or cannabis for their drug-of-choice, only to find that it was just a bridge back to their preferred drug. Cravings are one of the most common triggers for relapse, and getting high or intoxicated doesn’t improve anyone’s judgment or ability to resist cravings.

In my last post I mentioned euphoric recall (addicts dwelling on memories of the good times they’d had drinking and drugging, before getting addicted) as a trigger. This is one form of rumination, but addicts can also ruminate about how much they’d like to get high right now. This kind of thinking activates cravings that lead to relapses.

I’ve had some personal experience with this, as a recovering nicotine addict. What I found was that when I ruminated on how good it would feel to light up a cigarette, I relapsed time and again. Eventually I was able to identify my ruminations as a predictable relapse trigger, and to stop dwelling on thoughts about how I’d like to have a smoke. I still have occasional situation-specific cravings for tobacco, but I no longer feed the initial thought with more thoughts, and the cravings only last for a few seconds. After years of being  nicotine-free, the long-term rewards of being a non-smoker outweigh any momentary cravings I might have to light up again.

Relapse prevention, Part 1

I’ve written about my two years (1991-93) as a ward psychologist on the fledgling Detox/Rehab Ward of the University Hospital of the West Indies (UHWI), in Kingston Jamaica. When I started my Peace Corps tour of service, the ward had no treatment model other than the medical model, supported by Twelve Step meetings (Alcoholics Anonymous, Narcotics Anonymous). I introduced a relapse prevention curriculum that was adopted by the ward staff. When I recently checked out the UHWI Detox/Rehab Ward (now called the Addiction Treatment Services Unit) online, I was delighted to see that it’s still using a relapse prevention model. My Peace Corps legacy was a relapse prevention manual that I wrote for use on the ward. A Returned Peace Corps Volunteer who’d served at UHWI years after my departure told me that the manual had still been in use  when he was there.

A relapse prevention approach to recovery works well within the medical model, which – like Twelve Step programs – regards addiction as a disease. I introduced the patients on the ward to the relapse prevention model in my psycho-educational groups. Addiction, I said, is a chronic, progressive, relapsing disease that is ultimately fatal, if the disease progression isn’t arrested. Chronic means it doesn’t just go away at some point. Progressive means it gets worse over time. Relapsing means that most addicts will relapse multiple times before establishing long-term sobriety – if they ever succeed in doing that.

One of the advantages of the medical (or disease) model of addiction is that it helps some alcoholics/addicts to understand why they can’t control their drinking and/or drugging: they have a disease. Guilt and self-blame don’t generally help people to come to terms with their addiction. The medical model tells addicts that while they can never be “cured” of their chronic disease, they can halt its progression and stay in long-term recovery. This is why alcoholics in AA programs still refer to themselves as alcoholics, even if they haven’t had a drink in many years. They’re not ex-alcoholics, they’re in recovery. They may have stopped the disease progression, but they remain at risk of relapse. As any recovering addict will tell you, recovery happens one day at a time.

If you’re an addict, relapse prevention means learning what puts you at risk of relapsing. There are myriad ways that people who are struggling to stay in recovery unconsciously set themselves up for relapse. The first step in creating a personalized relapse prevention plan is to identify your triggers for relapse. Triggers can be people, places, things, activities, attitudes, emotions or thoughts. Different people have different triggers.

Recovering alcoholics may have to sever relationships with their old drinking buddies and stay away from bars and parties where alcohol is served, at least in early recovery, possibly permanently. If a lover is still drinking/using, a person in recovery may have to end the relationship. A recovering crack cocaine addict may need to stay away from the places he used to score and use, and might be triggered by the sight of a crack pipe or the smell of cocaine being smoked. Stress, anger, anxiety and depression might trigger a relapse. Thoughts like, “I’ll never drink again unless ________” can be a set-up for relapse, as can euphoric recall – dwelling on thoughts about the good times you used to have getting high, before you became addicted.

The second step in creating a relapse prevention plan is knowing in advance what you’re going to do instead of using, once you’ve been triggered. That might be going to a Twelve Step meeting, calling your sponsor, or checking yourself into Rehab. If you don’t have a plan for what you’ll do when you’re triggered, you’re probably going to relapse. A slip – defined as a single episode using your drug of choice or a bridge drug – need not become a relapse, if you have a plan and act on it. All too often, when an alcoholic gives in to temptation and drinks a six-pack after an extended period of sobriety, she thinks “I blew my recovery! I may as well go to the liquor store.” If, instead, she goes to an AA meeting or calls her sponsor, and admits what she’s done, she may prevent the slip from becoming a full-blown relapse. I used to quote an African proverb I’d heard somewhere: “If you want to avoid falling where you have fallen before, don’t examine where you fell, but where you slipped.”

I don’t mean to suggest that everyone with an addiction problem has to join a Twelve Step program and go to meetings for the rest of their lives, although for  some that may be exactly what they need to do. I’m convinced that there’s more than one road to recovery. I’ll write more about relapse prevention in another post.

Peace Corps service in Jamaica

I only met one Jamaican psychologist during my two years living in Kingston, serving as a Peace Corps Volunteer. She told me that there were only a few psychologists on the island. The University of the West Indies, on the outskirts of Kingston, didn’t have a psychology department. When Maria and I applied for Peace Corps service after our marriage in 1990, I never dreamed that I’d be employed as a psychologist in whatever developing country invited us to serve. (The more open an applicant is to serving wherever his/her services are needed, the higher the likelihood of acceptance.) With a bachelors degree in English, I thought I’d end up teaching English somewhere near where Maria worked. Maria was a psychiatric nurse – easy to place – and our Peace Corps recruiter initially referred to me as her “ball and chain” – not so easy to place. Maria was selected by Jamaica to serve as an instructor at the University Hospital of the West Indies (UHWI) School of Nursing. It just so happened that UHWI had just opened Jamaica’s first detox/rehab ward (mainly for alcoholics and crack cocaine addicts) and was in need of a ward psychologist. So from 1991-93 I wound up being one of Jamaica’s few practicing clinical psychologists.

The ward was initially run by a young psychiatrist who had just finished his residency at Johns Hopkins, and the staff consisted mostly of nurses, none of whom had experience working exclusively with substance abusers. When I reported for duty I discovered that the 8-bed ward had no treatment model (other than the medical model) and I had no job description. The only thing resembling treatment was several Twelve Step meetings  a week.

So I told the staff what I was qualified to do and they encouraged me to write my own job description: I would interview each new patient, review his/her medical record, and write a clinical assessment, with recommendations for the treatment plan. I would serve as a member of the treatment team. I would conduct group therapy sessions (psycho-educational and process  groups), and do individual and family therapy as needed.

I knew the program really needed to be based on a valid treatment model if it was to be effective. Other than the ward psychiatrist, I was the only treatment team member to have had training in substance abuse treatment. I knew that my first task as a Peace Corps Volunteer (PCV) was to listen and observe and learn, and to win the trust and confidence of the rest of the treatment team before I started making suggestions. However, I also started to work on a relapse prevention model that I’d introduce once I’d earned my place on the treatment team. I wanted to co-lead my groups with staff nurses, but they repeatedly declined. They were content to monitor the sessions from the nursing station.

I initially felt somewhat anxious at the prospect of leading groups. I was confident that group dynamics would be the same in Jamaica as in the U.S., but I knew that I had things to learn about Jamaican cultural norms, and I hadn’t yet developed an ear for Jamaican patois. English is the official language and all educated Jamaicans speak it clearly, with that unmistakable accent. But all Jamaicans also speak patois, and “deep patois” is initially unintelligible to English speakers. An effective group leader has to stay on top of not only everything that’s said in group, but also the non-verbal communication within the group. My initial test came early-on.

In a group session with all males, after a heated exchange between “Clarence” and “Desmond,” I thought, Did I just hear a death threat? Indeed I had, and I did an immediate intervention: “Threats of violence are not allowed in group, gentlemen. I know it’s almost lunch time, but we’re not leaving this room until Clarence not only takes back his threat, but means  what he says.” Before the end of the session, Clarence had retracted his threat, and shook hands with Desmond. Jamaican men tend to be macho, and it took all of my group leadership skills to stay in control during some contentious sessions.

The nurses were relieved to learn that I could stand up to angry Jamaican addicts. They never had to call Security, no matter how heated things got in group. More than once I had to break up fights. Most of the addicts I worked with came to respect me, and most seemed to like me. Some requested that I work with them individually. My psycho-educational group sessions focused on the relapse prevention skills that I was incorporating into my treatment model.

I soon “earned my spurs” with the ward staff, and began to feel like a valued member of the team. Everyone seemed pleased with the quality of the clinical services I provided, and in my second year of service I introduced my relapse prevention model. I’d written a relapse prevention manual with workbook exercises such as “Identifying your triggers for relapse.” I printed and assembled it at the Peace Corps office, and provided copies to all staff and patients. The model and the manual were approved by the treatment team and adopted into practice. When I left, after Maria and I had completed our two years of service, I felt a sense of accomplishment. A fellow Returned Peace Corps Volunteer (“Once a PCV, always a PCV”) later told me that when he’d served at UHWI, a few years after my service, the manual was still in use.

Peace Corps service can be very challenging, and many PCVs aren’t able to accomplish what they set out to do in their assignments, due to circumstances beyond their control.  The Country Director said to our training group, “If you feel like you’re ‘giving up’ two years of your life to serve in the Peace Corps, Jamaica doesn’t need you. You’re here to live two years of your life among the people of Jamaica.” The Peace Corps Mantra is “I got more than I gave.” Our lives were enriched by our two years in Jamaica. You can read the whole story in my first book, Two Years in Kingston Town: A Peace Corps Memoir, available online at Amazon and Barnes & Noble. For those with an interest in cross-cultural therapy, the book contains vivid descriptions of some of my clinical interventions in therapy groups. But it also describes places on the island that tourists seldom see, daily life in Kingston, and encounters with all sorts of interesting people.