What is a Relapse? (Terminally Unique, Pt. 13/21)
Published in Terminally Unique. Tags: Podcasts, Recovery.
What is a relapse? The question is straight forward, but the interpretation is where things become a little more opaque. Not to start things off in too dry a manner, but the Alcohol and Drug Foundation does well in defining it, explaining, “A relapse happens when a person stops maintaining his or her goal of reducing or avoiding use of alcohol or other drugs and returns to previous levels of use.” That could sum it up, but as I’ve explained, despite not drinking I haven’t always felt particularly sober when it comes to how I’ve attempted to manage my feelings through external means. Whether that be committing caloric suicide through binge eating as a means of tuning out feelings of loneliness, or distracting myself through compulsive use of social media or dating apps, it’s long felt like the question around what a relapse is might be more nuanced than a black-and-white focus on drinking or drug use. What happens when sobriety from alcohol is maintained, but the desire to do something shows up in other areas of life?
What inspires that desire isn’t clear, and from person to person it certainly isn’t consistent. To paraphrase Joseph Bailey from The Serenity Principle, whatever lies at the bottom of my motives is often a mystery. Through my participation in Alcoholics Anonymous and professional work in the treatment field, I can attest that the same holds true for many who “relapse,” only to return to a sober focus after days, weeks, or months, dumbstruck by what happened. And when asked what did happen, the genuine response is regularly along the lines of: “I don’t know.” For me, personally, the desire could relate to a vague sense of boredom sometimes; loneliness others; mood; or nothing at all. I once wrote in a journal entry, calling it “a nagging inability to be alone with myself, […] an emotionally-driven desire to provoke a change in myself; not necessarily to make myself feel better, just make myself feel different.” This contributes to my hang-up around what a relapse actually is, because it’s hardly a binary concept when considering the (sometimes) problematic novelty-seeking behaviors that can be used in lieu of alcohol or drugs.
Terence Gorski and Merlene Miller’s Staying Sober: A Guide for Relapse Prevention attempts to create a pathway of criteria that outline the “relapse progression,” which includes several distinct phases such as: stress, denial, post-acute withdrawal symptoms, behavior change, breakdown in social structure, loss of control of judgment, loss of behavioral control, option reduction, acute degeneration, and addictive use. Often this process isn’t a gradual shift into addictive behaviors though, but an instantaneous switch of personal constitution; particularly early in sobriety before new habits and patterns of behavior have had any time to build momentum. I call these moments “extinction bursts,” where capacity for choice and decision making isn’t lost, but is significantly influenced by pre-existing habitual patterns of addictive thinking. This is a useful framework when considering the “empathy gap” term used in the last chapter; “thought and behavior cannot be predicted when people find themselves in hot or cold states of mind” for those not even struggling with chemical dependency. I don’t pretend to know much about biochemistry, but think about the brain of someone who’s regularly used to cranking life up to an eleven in addictive addiction, who’s then told they should seek a balanced approach in recovery and strive for a five? As anyone who’s tried to change a pattern or behavior in their life know, rarely is that change resolved by a simple act of subtraction; it’s very difficult to replace an emotionally and physically relied upon “something” with a void of nothing.
To establish a better understanding of what any particular individual’s relapse process looks like, an exercise is often used in rehabs called a relapse autopsy. This helps peel the layers of the onion back, systematically identifying what influences might have contributed to the usage event in order to gain a better understanding of what to watch out for in the future. These “influences” can be internal or external, and I want to outline an extensive list so as to depict just how wide-ranging they can be. Warning signs of relapse include: Self-pity, isolation, rage or other outbursts, increased resentments, increased codependent behaviors, perfectionistic behaviors or feelings, increased triggers of past traumas, issues with concurrent medical or psychiatric problems, avoidance, defensiveness, family dysfunction, over-committing to others, compulsive eating or food restriction, poor boundary setting, misguided beliefs surrounding potential to control addictive behaviors, trying to impose recovery on others, being overly controlling, spending money recklessly, being overly focused on recovery as an outcome, bouts of depression, loss of constructive planning, or all or nothing thinking. The list goes on from there, but when considering what relapse might be, on a personal level, it’s important to determine what the individual markers might be that typically signal a shift in relapse modes of thought. For me, personally, my big red flags come not only when I isolate from others, but when I reason with myself why I shouldn’t worry about exercising, eating healthy, or generally just taking care of myself. The moments that promote just a little bit of addictive behavior won’t hurt, I tell myself, as though my track record surrounding a little bit of addictive behavior spiraling into a harmful and damaging tailspin doesn’t count for anything.
The reason for establishing a distinction between what a relapse is, as perceived in the broader recovery community, and what it has become personally, is two fold. Recognizing the broader implications of how dysfunctional patterns of thinking promote continued destructive behaviors, regardless of whether alcohol is being used, is critical within recovery’s broader scope of nurturing a healthier relationship with oneself. A decade ago I made the argument against A.A.’s description of alcoholism as a pathological “malady,” revealing “itself as an illness which cannot simply be remedied or cured, leaving those affected perpetually in a state of limbo.” My frustration was with the idea that the system promoted a ceaseless state of being in recovery, versus ever being recovered. At nearly eight years sober from alcohol, am I recovered now? A decade ago I would have argued that I am, but in realigning myself with a more personal definition of what recovery is to me, I’m more comfortable with saying that I’m still in recovery due to the ongoing relationship with concepts such as self-deception surrounding relapse behaviors and problematic patterns of thinking. Those are just a couple of the areas where I might never find myself fully “recovered.”
The second reason for the distinction is because of the actual paradigm created by A.A. relating to a black-and-white approach to relapse, and how it promotes continued stigma. Not unlike how the word “alcoholic” is a stigmatizing term, with something like “person with alcohol use disorder” now favored in its place, “relapse” also carries with it its own stigmatizing association compared to a person-centered phrase like “usage event.” As outlined here, relapse is a combination of thought, feeling, and action, existing within a hazy middle ground between the three. A.A. inherently promotes a binary view of relapse, where someone is either sober or not sober. Perhaps unintentionally, this blurs the role autonomy and personal decision making might have once a slip-up occurs. I liken it to someone who gets a flat tire on their car, only to then say “screw it” and slash the remaining three. Why not go all out if relapse conceptually exists within an all or nothing framework? Approaching relapse in this way promotes myopic thinking which can create more harm and suffering as a result. Further, A.A.’s approach reconciles relapse with a personality flaw or “character defect,” which proposes to overlay a moral code over disordered thinking. As Dennis Daley writes in his paper “Relapse Prevention with Substance Abusers: Clinical Issues and Myths,” he notes, “Teaching clients to expect one episode of use to lead to total loss of control may set the expectation that initial use cannot be curtailed before a full-blown relapse occurs.”
Recovery is not linear for anyone, and relapse is a variable that plays a role with or without use of a particular substance. The question of what exactly relapse is doesn’t bear quite as much value in the big picture as the question of what is to be done about it? When distorted thinking is continually rewarded by behavior that acts on addictive urges, it becomes increasingly difficult to correct negative patterns than simply positively thinking one’s way out of self-destructive action. Though, for whatever criticisms I’ve laid out against A.A., it’s still valuable to look at how its 12 Steps actually combat this; you might be surprised by how much they align with modern therapeutic interventions in doing so.
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[The track opening and closing the episode is called “styles.”]